Block 3 Flashcards
Inspection of the left ventricle reveals all except which of the following?
Papillary muscles
Trabeculae carnae
Chordae tendinae
Conus arteriosus
Openings of the venae cordis minimae
The conus arteriosus (infundibulum) is the smooth walled outflow tract of the right ventricle leading to the pulmonary trunk.
A 23 year old lady with troublesome axillary hyperhidrosis is undergoing a thorascopic sympathectomy to treat the condition. Which of the following structures will need to be divided to access the sympathetic trunk?
Intercostal vein
Intercostal artery
Parietal pleura
Visceral pleura
None of the above
The sympathetic chain lies posterior to the parietal pleura. During a thorascopic sympathetomy this structure will need to be divided. The intercostal vessels lie posteriorly. They may be damaged with troublesome bleeding but otherwise are best left alone as deliberate division will not improve surgical access
A 44 year old man undergoes a distal gastrectomy for cancer. He is slightly anaemic and therefore receives a transfusion of 4 units of packed red cells to cover both the existing anaemia and associated perioperative blood loss. He is noted to develop ECG changes that are not consistent with ischaemia. What is the most likely cause?
Hyponatraemia
Hyperkalaemia
Hypercalcaemia
Metabolic alkalosis
Hypernatraemia
The transfusion of packed red cells has been shown to increase serum potassium levels. The risk is higher with large volume transfusions and with old blood.
Treatment of hyperhidrosis possible complications
For treatment of hyperhidrosis the sympathetic denervation can be achieved by removing the second and third thoracic ganglia with their rami. Removal of T1 will cause a Horners syndrome and is therefore not performed.
In which space is a lumbar puncture performed?
Subdural space
Epidural space
Subarachnoid space
Extradural space
Intraventricular space
Samples of CSF are normally obtained by inserting a needle between the third and fourth lumbar vertebrae. The tip of the needle lies in the sub arachnoid space, the spinal cord terminates at L1 and is not at risk of injury. Clinical evidence of raised intracranial pressure is a contraindication to lumbar puncture.
A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count of 50. She is due to undergo a splenectomy. What is the optimal timing of a platelet transfusion in this case?
24 hours pre-operatively
2 hours pre-operatively
Whilst making the skin incision
After ligation of the splenic artery
On removal of the spleen
ITP causes splenic sequestration of platelets. Therefore a platelet transfusion should be carefully timed. Too soon and it will be ineffective. Too late and unnecessary bleeding will occur. The optimal time is after the splenic artery has been ligated.
Indications for splenectomy
Trauma: 1/4 are iatrogenic
Spontaneous rupture: EBV
Hypersplenism: hereditary spherocytosis or elliptocytosis etc
Malignancy: lymphoma or leukaemia
Splenic cysts, hydatid cysts, splenic abscesses
Post-splencetomy changes
Platelets will rise first (therefore in ITP should be given after splenic artery clamped)
Blood film will change over following weeks, Howell Jolly bodies will appear
Other blood film changes include target cells and Pappenheimer bodies
Increased risk of post splenectomy sepsis, therefore prophylactic antibiotics and pneumococcal vaccine should be given.
Epidemiology of colonoscopy
5 out of 10 will have a normal exam
4 out of 10 will have polyps
1 out of 10 will have cancer
What patients need referral for colonoscopy
- Altered bowel habit for more than six weeks
- New onset of rectal bleeding
- Symptoms of tenesmus
A 21 year old man is stabbed in the antecubital fossa. A decision is made to surgically explore the wound. At operation the surgeon dissects down onto the brachial artery. A nerve is identified medially, which nerve is it likely to be?
Radial
Recurrent branch of median
Anterior interosseous
Ulnar
Median
Median
Most common primary liver tumours
Cholangiocarcinoma and HCC.
Metastatic disease accounts for 95% of all liver malignancies
Diagnosis of HCC
CT/MRI
AFP
Biopsy should be avoided as it seeds tumour cells.
In diagnostic uncertainty, serial CT and aFP measurents are prefered
Staging of HCC
Liver MRI, CT CAP
Use of PET CT in HCC
Can be used to identify occult nodal disease
Treatment of HCC
Surgical resection is the mainstay of treatment in operable cases. In patients with a small primary tumour in a cirrhotic liver whose primary disease process is controlled, consideration may be given to primary whole liver resection and transplantation.
Liver resections are an option but since most cases occur in an already diseased liver the operative risks and post-operative hepatic dysfunction are far greater than is seen following metastectomy.
These tumours are not particularly chemo or radiosensitive however, both may be used in a palliative setting. Tumour ablation is a more popular strategy.
Survival in HCC
15% at 5 years
Tumour markers in cholangiocarcinoma
CA 19-9, CEA and CA 125 are often elevated
Diagnosis of cholangiocarcinoma
Patients will typically have an obstructive picture on liver function tests.
CA 19-9, CEA and CA 125 are often elevated
CT/ MRI and MRCP are the imaging methods of choice.
Treatment of cholangiocarcinoma
Surgical resection offers the best chance of cure. Local invasion of peri hilar tumours is a particular problem and this coupled with lobar atrophy will often contra indicate surgical resection.
Palliation of jaundice is important, although metallic stents should be avoided in those considered for resection.
Survival in cholangiocarcinoma
5-10% 5ys
A 56 year old man has long standing chronic pancreatitis and develops pancreatic insufficiency. Which of the following will be absorbed normally?
Fat
Protein
Folic acid
Vitamin B12
None of the above
Pancreatic lipase is required for digestion of fat, Proteases facilitate protein and B12 absorption. Folate digestion is independent of the pancreas.
Rate of pancreatic secretions
1000-1500mL per 24 hours
pH 8
Substances secreted by acinar cells of the pancreas
Trypsinogen
Procarboxylase
Amylase
Elastase
Activation of trypsin
Trypsinogen is converted via enterokinase to active trypsin in the duodenum. Trypsin then activates the other inactive enzymes
A 65 year old man with long standing atrial fibrillation develops an embolus to the lower leg. The decision is made to perform an embolectomy, utilising a trans popliteal approach. After incising the deep fascia, which of the following structures will the surgeons encounter first on exploring the central region of the popliteal fossa?
Popliteal vein
Common peroneal nerve
Popliteal artery
Tibial nerve
None of the above
The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the popliteal fossa.
Theme: Gastrointestinal bleeding
A.Haemorrhoids
B.Meckels diverticulum
C.Angiodysplasia
D.Colonic cancer
E.Diverticular bleed
F.Ulcerative colitis
G.Ischaemic colitis
Please select the most likely cause of colonic bleeding for the scenario given. Each option may be used once, more than once or not at all
A 73 year old lady is admitted with a brisk rectal bleed. She is otherwise well and the bleed settles. On examination her abdomen is soft and non tender. Elective colonoscopy shows a small erythematous lesion in the right colon, but no other abnormality.
A 23 year old man complains of passing bright red blood rectally. It has been occurring over the past week and tends to occur post defecation. He also suffers from pruritus ani.
A 63 year old man presents with episodic rectal bleeding the blood tends to be dark in colour and may be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6 weeks previously.
The correct answer is Angiodysplasia
Angiodysplasia can be difficult to identify and treat. The colonoscopic stigmata are easily missed by poor bowel preparation.
Haemorrhoids
Classical haemorrhoidal symptoms include bright red rectal bleeding, it typically occurs post defecation and is noticed on the toilet paper and in the toilet pan. It is usually painless, however, thrombosed external haemorrhoids may be very painful.
Ischaemic colitis
The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through the marginal may be imperfect.
Why does colonic bleeding rarely present as malaena?
This typically presents as bright red or dark red blood per rectum. Colonic bleeding rarely presents as malaena type stool, this is because blood in the colon has a powerful laxative effect and is rarely retained long enough for transformation to occur and because the digestive enzymes present in the small bowel are not present in the colon. Up to 15% of patients presenting with haemochezia will have an upper gastrointestinal source of haemorrhage.
Bleeding may be brisk in advanced cases, diarrhoea is commonly present. Abdominal x-ray may show featureless colon.
Colitis
Acute diverticulitis often is not complicated by major bleeding and diverticular bleeds often occur sporadically. 75% all will cease spontaneously within 24-48 hours. Bleeding is often dark and of large volume.
Diverticular disease
Colonic cancers often bleed and for many patients this may be the first sign of the disease. Major bleeding from early lesions is uncommon
Cancer
Typically bright red bleeding occurring post defecation. Although patients may give graphic descriptions bleeding of sufficient volume to cause haemodynamic compromise is rare.
Haemorrhoidal bleeding
Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of symptoms. The right side of the colon is more commonly affected.
Angiodysplasia
Management of lower GI bleed
Supportive with correction of any haemodynamic compromise
When haemorrhoidal bleeding is suspected a proctosigmoidoscopy is reasonable as attempts at full colonoscopy are usually time consuming and often futile.
In the unstable patient the usual procedure would be an angiogram (either CT or percutaneous), when these are performed during a period of haemodynamic instability they may show a bleeding point and may be the only way of identifying a patch of angiodysplasia.
In others who are more stable the standard procedure would be a colonoscopy in the elective setting. In patients undergoing angiography attempts can be made to address the lesion in question such as coiling. Otherwise surgery will be necessary.
In patients with ulcerative colitis who have significant haemorrhage the standard approach would be a sub total colectomy, particularly if medical management has already been tried and is not effective.
Indications for surgery in lower GI bleed
Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension
Surgical management of lower GI bleed
Selective mesenteric embolisation if life threatening bleeding. This is most helpful if conducted during a period of relative haemodynamic instability. If all haemodynamic parameters are normal then the bleeding is most likely to have stopped and any angiography normal in appearance. In many units a CT angiogram will replace selective angiography but the same caveats will apply.
If the source of colonic bleeding is unclear; perform a laparotomy, on table colonic lavage and following this attempt a resection. A blind sub total colectomy is most unwise, for example bleeding from an small bowel arterio-venous malformation will not be treated by this manoeuvre.
A 39 year old man has suffered from terminal ileal Crohns disease for the past 20 years. Which condition is he least likely to develop?
Gallstones
Malabsorption
Pyoderma gangrenosum
Amyloidosis
Feltys syndrome
Felteys syndrome:
Rheumatoid disease
Splenomegaly
Neutropenia
Feltys syndrome is associated with rheumatoid disease. Individuals with long standing Crohns disease are at risk of gallstones because of impairment of the enterohepatic recycling of bile salts. Formation of entero-enteric fistulation may produce malabsorption. Amyloidosis may complicate chronic inflammatory states.
Commonest disease pattern in Crohns
The commonest disease pattern in Crohns is stricturing terminal ileal disease and this often culminates in an ileocaecal resection.
A 56 year old male presents to the acute surgical take with severe abdominal pain. He is normally fit and well. He has no malignancy. The biochemistry laboratory contacts the ward urgently, his corrected calcium result is 3.6 mmol/l. What is the medication of choice to treat this abnormality?
IV Pamidronate
Oral Alendronate
Dexamethasone
Vitamin D
Resonium salts
IV Pamidronate is the drug of choice as it most effective and has long lasting effects. Calcitonin would need to be given with another agent, to ensure that the hypercalcaemia is treated once its short term effects wear off. IV zoledronate is preferred in scenarios associated with malignancy.
Management of hypercalcaemia
ABC
IV fluid resuscitation wiht 3-6L NS in 24 hours
Concurrent administration of calcitonin
Medical therapy (usually if corrected calcium >3.0mmol/l)
When is urgent management of hypercalcaemia indicated?
Ca >3.5
Reduced consciousness
Severe abdo pain
Pre renal failure
A 53 year old man is undergoing a distal pancreatectomy for trauma. Which of the following vessels is responsible for the arterial supply to the tail of the pancreas?
Splenic artery
Pancreaticoduodenal artery
Gastric artery
Hepatic artery
Superior mesenteric artery
Pancreatic head is supplied by the pancreaticoduodenal artery
Pancreatic tail is supplied by branches of the splenic artery
There is an arterial watershed in the supply between the head and tail of the pancreas. The head is supplied by the pancreaticoduodenal artery and the tail is supplied by branches of the splenic artery.
Venous drainage of the pancreas
Head: superior mesenteric vein
Body and tail: splenic vein
A 43 year old lady presents with varicose veins and undergoes a saphenofemoral disconnection, long saphenous vein stripping to the ankle and isolated hook phlebectomies. Post operatively she notices an area of numbness superior to her ankle. What is the most likely cause for this?
Sural nerve injury
Femoral nerve injury
Saphenous nerve injury
Common peroneal nerve injury
Superficial peroneal nerve injury
The sural nerve is related to the short saphenous vein. The saphenous nerve is related to the long saphenous vein below the knee and for this reason full length stripping of the vein is no longer advocated.
Course of the long saphenous
1st digit where the dorsal vein merges with the dorsal venous arch of the foot.
Passes anterior to the medial malleolus and runs up the medial side of the leg.
At the knee it runs over the posterior border of the medial epicondyle of the femur.
Passes laterally to lie on the anterior surface of the thigh before entering the saphenous opening in the fascia lata.
Joins the femoral vein in the femoral triangle at the SFJ
Tributaries of the saphenous vein
Medial marginal
Superficial epigastric
Superficial iliac circumflex
Superficial external pudendal veins
Theme: Parasitic infections
A.Giardia Infection
B.Cryptosporidium infection
C.Clonorchis sinensis infection
D.Ancylostoma duodenale infection
E.Ascaris lumbricoides infection
F.Echinococcus granulosus infection
G.Enterobius vermicularis infection
Please select the most likely infective organism for the scenario given. Each option may be used once, more than once or not at all.
3.A 6 year old boy presents with symptoms of recurrent pruritus ani. On examination there is evidence of a small worm like structure protruding from the anus.
A 58 year old man is reviewed in the clinic following a successful cadaveric renal transplant the previous year. He has been able to return to work as a swimming instructor. Over the past week he reports that he has been suffering from recurrent episodes of diarrhoea. It has made him feel lethargic and exhausted. Stool microscopy shows evidence of cysts.
A 25 year old man returns from a backpacking holiday in India. He presents with symptoms of coughing and also of episodic abdominal discomfort. Peri anal examination is normal. Stool microscopy demonstrates both worms and eggs within the faeces.
The correct answer is Enterobius vermicularis infection
Infection with enterobius is extremely common. Pruritus is the main symptom, as there is a lack of tissue invasion it is rare for individuals to have any signs of systemic sepsis.
Cryptosporidium infection
Cryptosporidium is associated with infection, particularly in those who are immunocompromised. Diarrhoea is the main disease. The cysts are typically identified on stool microscopy.
The correct answer is Ascaris lumbricoides infection
Infection with Ascaris lumbricoides usually occurs after individuals have visited places like sub Saharan Africa or the far east. Unlike ancylostoma duodenale infection there is usually evidence of both worms and eggs in the stool. The absence of pruritus makes enterobius less likely. The presence of coughing may be due to the migration of the larva through the lungs.
Due to organism Enterobius vermicularis
Common cause of pruritus ani
Diagnosis usually made by placing scotch tape at the anus, this will trap eggs that can then be viewed microscopically
Treatment is with mebendazole
Enterobiasis
Hookworms that anchor in proximal small bowel
Most infections are asymptomatic although may cause iron deficiency anaemia
Larvae may be found in stools left at ambient temperature, otherwise infection is difficult to diagnose
Infection occurs as a result of cutaneous penetration, migrates to lungs, coughed up and then swallowed
Treatment is with mebendazole
Ancylostoma duodenale
Due to infection with roundworm Ascaris lumbricoides
Infections begin in gut following ingestion, then penetrate duodenal wall to migrate to lungs, coughed up and swallowed, cycle begins again
Diagnosis is made by identification of worm or eggs within faeces
Treatment is with mebendazole
Ascariasis
Due to infection with Strongyloides stercoralis
Rare in west
Organism is a nematode living in duodenum of host
Initial infection is via skin penetration. They then migrate to lungs and are coughed up and swallowed. Then mature in small bowel are excreted and cycle begins again
An auto infective cycle is also recognised where larvae will penetrate colonic wall
Individuals may be asymptomatic, although they may also have respiratory disease and skin lesions
Diagnosis is usually made by stool microscopy
In the UK mebendazole is used for treatment
Strongyloidiasis
Protozoal infection
Organisms produce cysts which are excreted and thereby cause new infections
Symptoms consist of diarrhoea and cramping abdominal pains. Symptoms are worse in immunosuppressed people
Cysts may be identified in stools
Treatment is with metronidazole
Cryptosporidium
Diarrhoeal infection caused by Giardia lamblia (protozoan)
Infections occur as a result of ingestion of cysts
Symptoms are usually gastrointestinal with abdominal pain, bloating and passage of soft or loose stools
Diagnosis is by serology or stool microscopy
First line treatment is with metronidazole
Giardiasis
A 23 year old women has undergone a pan proctocolectomy and ileoanal pouch because she suffers from familial adenomatous polyposis coli. What is the commonest extra colonic lesion in this disorder?
Gastric fundal polyps
Trichilemmomas
Duodenal polyps
Fibrocystic disease of the breast
Skull osteomas
Duodenal polyps occur in up to 100% of patients with FAP if follow up is continued for long enough. Duodenal cancer has an incidence of 4-10%.
Duodenal polyps are the commonest extra colonic lesion in FAP. Gastric fundal polyps are seen in 50% of patients. Skull osteomas are seen in Gardeners syndrome which is a variant of FAP.
Which of the following muscles does not attach to the radius?
Pronator quadratus
Biceps
Brachioradialis
Supinator
Brachialis
The brachialis muscle inserts into the ulna. The other muscles are all inserted onto the radius.
The oxygen-haemoglobin dissociation curve is shifted to the right in which of the following scenarios?
Hypothermia
Respiratory alkalosis
Low altitude
Decreased 2,3-DPG in transfused red cells
Chronic iron deficiency anaemia
Mnemonic to remember causes of right shift of the oxygen dissociation curve:
CADET face RIGHT
C O2
A cidosis
2,3-DPG
E xercise
T emperature
The curve is shifted to the right when there is an increased oxygen requirement by the tissue. This includes:
Increased temperature
Acidosis
Increased DPG:
DPG is found in erythrocytes and is increased during glycolysis. It binds to the Hb molecule, thereby releasing oxygen to tissues. DPG is increased in conditions associated with poor oxygen delivery to tissues, such as anaemia and high altitude.
How does hypocitraturia cause increased risk of calcium oxalate stones?
Citrate forms complexes with Ca making it more soluble
How does hyperuricosuria cause calcium oxalate stones?
Hyperuricosuria may cause uric acid stones to which calcium oxalate binds
Formation of calcium phosphate stones
May occur in renal tubular acidosis, high urinary pH increases supersaturation of urine with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase risk of stone formation (types 2 and 4 do not)
Radio-opaque stones (composition similar to bone)
A pathologist is examining a histological section and identifies Hassall’s corpuscles. With what are they most commonly associated?
Follicular carcinoma of the thyroid
Medulla of the thymus
Medulla of the spleen
Medulla of the kidney
Fundus of the stomach
Hassall’s corpuscles are the concentric ring of epithelial cells seen in the medulla of the thymus.
A 25 year old man is stabbed in the upper arm. The brachial artery is lacerated at the level of the proximal humerus, and is being repaired. A nerve lying immediately lateral to the brachial artery is also lacerated. Which of the following is the nerve most likely to be?
Ulnar nerve
Median nerve
Radial nerve
Intercostobrachial nerve
Axillary nerve
The brachial artery begins at the lower border of teres major and terminates in the cubital fossa by branching into the radial and ulnar arteries. In the upper arm the median nerve lies closest to it in the lateral position. In the cubital fossa it lies medial to it.
A 63 year old man undergoes an upper GI endoscopy and adrenaline injection for a large actively bleeding duodenal ulcer. He remains stable for 6 hours and the nurses then call because he has passed 400ml malaena and has become tachycardic (pulse rate 120) and hypotensive (Bp 80/40). What is the best option?
Reassure that blood trapped in the upper portion of the gastrointestinal system will pass and that this episode will resolve with phosphate enema
Perform a repeat upper GI endoscopy
Perform a laparotomy and under-running of the ulcer
Administer tranexamic acid and intravenous proton pump inhibitors
Insert a Minnesota tube
The decision as to how best to manage patients with re-bleeding is difficult. Whilst it is tempting to offer repeat endoscopy, this intervention is best used on those with small ulcers. Large posteriorly sited duodenal ulcers are at high risk for re-bleeding and the timeframe of this event suggests that primary endoscopic haemostasis was inadequate. Surgery thus represents the safest way forward.
Small volume of fresh blood, often streaking vomit. Malaena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms
Oesophagitis
Usually small volume of blood, except as pre terminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy managed.
Cancer
Typically brisk small to moderate volume of bright red blood following bout of repeated vomiting. Malaena rare. Usually ceases spontaneously.
Mallory Weiss Tear
Usually large volume of fresh blood. Swallowed blood may cause malaena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.
Varices
May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.
Gastric cancer
Often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically.
Dieulafoy Lesion
Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise.
Diffuse erosive gastritis
Small low volume bleeds more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis.
Gastric ulcer
What is a consideration in haematemesis in patients with previous AAA surgery?
aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.
Indications for surgery in UGI bleed?
Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension
Surgical management of duodenal ulcer
Laparotomy, duodenotomy and under running of the ulcer. If bleeding is brisk then the ulcer is almost always posteriorly sited and will have invaded the gastroduodenal artery. Large bites using 0 Vicryl are taken above and below the ulcer base to occlude the vessel. The duodenotomy should be longitudinal but closed transversely to avoid stenosis.
Surgical management of gastric ulcer
Under-running of the bleeding site
Partial gastrectomy-antral ulcer
Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery)
Total gastrectomy if bleeding persists
What can be used to stratify UGI bleed pre-endoscopy?
Blatchford score
What can be used to stratify UGI bleeds post endoscopy?
Rockall score
PPI pre-endoscopy in UGI bleed
The requirement for pre endoscopic proton pump inhibition is contentious. In the UK the National Institute of Clinical Excellence guidelines suggest the pre endoscopic PPI therapy is unnecessary. Whilst it is accepted that such treatment has no impact on mortality or morbidity a Cochrane review of this practice in 2007 did suggest that it reduced the stigmata of recent haemorrhage at endoscopy. As a result many will still administer PPI to patients prior to endoscopic intervention.
A 64 year old man presents to the clinic with right upper quadrant discomfort. He has never attended the hospital previously and is usually well. He has just retired from full time employment as a machinist in a PVC factory. CT scanning shows a large irregular tumour in the right lobe of his liver. Which of the following lesions is the most likely?
Liposarcoma
Angiosarcoma
Hamartoma
Hyatid liver disease
Benign angioma
Angiosarcoma of the liver is a rare tumour. However, it is linked to working with vinyl chloride, as in this case. Although modern factories minimise the exposure to this agent, this has not always been the case.
What is the course of the median nerve relative to the brachial artery in the upper arm?
Medial to anterior to lateral
Lateral to posterior to medial
Medial to posterior to lateral
Medial to anterior to medial
Lateral to anterior to medial
Relations of median nerve to the brachial artery:
Lateral -> Anterior -> Medial
The median nerve descends lateral to the brachial artery, it usually passes anterior to the artery to lie on its medial side. It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow. It enters the forearm between the two heads of the pronator teres muscle.
A 45 year old man undergoes a sub total colectomy and formation of end ileostomy. What is the most likely sodium content per litre of ileostomy fluid?
120 mmol
60 mmol
20 mmol
210 mmol
180 mmol
Investigators in the 1960’s dehydrated and measured the sodium content of ileostomy effluent and determined this concentration. Not an experiment many would care to repeat! (120)
Which of the following muscle relaxants will tend to incite neuromuscular excitability following administration?
Atracurium
Suxamethonium
Vecuronium
Pancuronium
None of the above
Suxamethonium may induce generalised muscular contractions following administration. This may raise serum potassium levels.
Depolarising neuromuscular blocker
Inhibits action of acetylcholine at the neuromuscular junction
Degraded by plasma cholinesterase and acetylcholinesterase (affected by lack of acetylcholinesterase)
Fastest onset and shortest duration of action of all muscle relaxants
Produces generalised muscular contraction prior to paralysis
Adverse effects include hyperkalaemia, malignant hyperthermia, delayed recovery
Suxamethonium
Non depolarising neuromuscular blocking drug
Duration of action usually 30-45 minutes
Generalised histamine release on administration may produce facial flushing, tachycardia and hypotension
Not excreted by liver or kidney, broken down in tissues by hydrolysis
Reversed by neostigmine
Atracurium
Non depolarising neuromuscular blocking drug
Duration of action approximately 30 - 40 minutes
Degraded by liver and kidney and effects prolonged in organ dysfunction
Effects may be reversed by neostigmine
Vecuronium
Non depolarising neuromuscular blocker
Onset of action approximately 2-3 minutes
Duration of action up to 2 hours
Effects may be partially reversed with drugs such as neostigmine
Pancuronium
A 32 year old man is involved in a house fire and sustains extensive partial thickness burns to his torso and thigh. Two weeks post incident he develops oedema of both lower legs. The most likely cause of this is:
Iliofemoral deep vein thrombosis
Venous obstruction due to scarring
Hypoalbuminaemia
Excessive administration of intravenous fluids
None of the above
Loss of plasma proteins is the most common cause of oedema developing in this time frame.
Which of the following blood products can be administered to a non ABO matched recipient?
Whole blood
Platelets
Packed red cells
Stem cells
Cryoprecipitate
In the UK, platelets either come from pooling of the platelet component from four units of whole donated blood, called random donor platelets, or by plasmapharesis from a single donor. The platelets are suspended in 200-300 ml of plasma and may be stored for up to 4 days in the transfusion laboratory where they are continually agitated at 22oC to preserve function. One adult platelet pool raises the normal platelet count by 30,000 to 60,000 platelets litre. ABO identical or compatible platelets are preferred but not necessary in adults; but rhesus compatibility is required in recipients who are children and women of childbearing age to prevent haemolytic disease of the newborn.
Used for transfusion in chronic anaemia and cases where infusion of large volumes of fluid may result in cardiovascular compromise. Product obtained by centrifugation of whole blood.
Packed red cells
Usually administered to patients who are thrombocytopaenic and are bleeding or require surgery. It is obtained by low speed centrifugation.
Platelet rich plasma
Prepared by high speed centrifugation and administered to patients with thrombocytopaenia.
Platelet concentrate
Prepared from single units of blood.
Contains clotting factors, albumin and immunoglobulin.
Unit is usually 200 to 250ml.
Usually used in correcting clotting deficiencies in patients with hepatic synthetic failure who are due to undergo surgery.
Usual dose is 12-15ml/Kg-1.
It should not be used as first line therapy for hypovolaemia.
Fresh frozen plasma
Formed from supernatant of FFP.
Rich source of Factor VIII and fibrinogen.
Allows large concentration of factor VIII to be administered in small volume.
Cryoprecipitate
Removal of all plasma from a blood unit and substitution with:
Sodium chloride
Adenine
Anhydrous glucose
Mannitol
Up to 4 units of SAG M Blood may be administered. Thereafter whole blood is preferred. After 8 units, clotting factors and platelets should be considered.
SAG-Mannitol Blood
Which of the following is not a content of the cavernous sinus?
Oculomotor nerve
Internal carotid artery
Opthalmic nerve
Abducens nerve
Optic nerve
Mnemonic for contents of cavernous sinus:
O TOM CAT
Occulomotor nerve (III)
Trochlear nerve (IV)
Ophthalmic nerve (V1)
Maxillary nerve (V2)
Carotid artery
Abducent nerve (VI)
T
OTOM=lateral wall components
CA= components within sinus
The optic nerve lies above and outside the cavernous sinus.
Theme: Renal transplant complications
A.Acute tubular necrosis
B.Renal artery thrombosis
C.Bladder occlusion
D.Ureteric occlusion
E.Acute rejection
F.Acute on chronic rejection
G.Hyperacute rejection
For each of the scenarios given please select the most likely underlying process from the list below. Each option may be used once, more than once or not at all.
A 45 year old man with end stage renal failure undergoes a cadaveric renal transplant. The transplanted organ has a cold ischaemic time of 26 hours and a warm ischaemic time of 54 minutes. Post operatively the patient receives immunosuppressive therapy. Ten days later the patient has gained weight, becomes oliguric and feels systemically unwell. He also complains of swelling over the transplant site that is painful.
A 44 year old man with end stage renal failure undergoes a live donor renal transplant. During the immediate post operative period a good urine output is recorded. However, on return to the ward the nursing staff notice that the urinary catheter is no longer draining. However, the urostomy is continuing to drain urine.
A 43 year old man undergoes a live donor renal transplant. The donor’s right kidney is anastomosed to the recipient. On removal of the arterial clamps there is good urinary flow noted and the wounds are closed. On return to the ward the nurses notice that the patient suddenly becomes anuric and irrigation of the bladder does not improve the situation.
The correct answer is Acute rejection
The features described are those of worsening graft function and acute rejection. The fact that there is a 10 day delay goes against hyperacute rejection. Cold ischaemic times are a major factor for delayed graft function. However, even 26 hours is not incompatible with graft survival.
Bladder occlusion
The most likely explanation for this event is a blocked catheter. This may be the result of blood clot from the ureteric anastomosis. Bladder irrigation will usually resolve the problem.
The correct answer is Renal artery thrombosis
Right sided live donor transplants are extremely rare. This is because the vena cava precludes mobilisation of the right renal artery. The short right renal artery that is produced therefore presents a major challenge. The sudden cessation of urine output in this context is highly suggestive of an acute thrombosis. Delay in thrombectomy beyond 1 hour almost inevitably results in graft loss.
What are the significant technical complications of renal transplant?
Ureteric anastomosis
Warm ischaemic time (graft survival is directly related to this)
Long warm ischaemic times increase the risk of ATN.
Renal transplant
Sudden complete loss of urine output
?Renal artery thrombosis
Immediate surgery may salvage the graft, delays beyond 30 minutes are associated with a high rate of graft loss
Renal transplant
Uncontrolled hypertension, allograft dysfunction and oedema
Renal artery stenosis
Angioplasty is the treatment of choice
Renal transplant
Pain and swelling over the graft site, haematuria and oliguria
Renal vein thrombosis
The graft is usually lost
Renal transplant
Diminished urine output, rising creatinine, fever and abdominal pain
Urine leaks
USS shows perigraft collection, necrosis of ureter tip is the commonest cause and the anastomosis may need revision
Renal transplant
Common complication (occurs in 15%), may present as a mass, if large may compress ureter
Lymphocele
May be drained with percutaneous technique and sclerotherapy, or intraperitoneal drainage
A 73 year old lady is admitted for a laparoscopic cholecystectomy. During her pre-operative assessment it is noted that she is receiving furosemide for the treatment of hypertension. Where is the site of action of this diuretic?
Proximal convoluted tubule
Descending limb of the loop of Henle
Ascending limb of the loop of Henle
Distal convoluted tubule
Collecting ducts
Action of furosemide = ascending limb of the loop of Henle
Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl.
MOA Frusemide
Ascending limb of loop of Henle
Na/K 2Cl
MOA thiazides
DCT and connecting segment
Na Cl carrier
MOA spironolactone
Cortical collecting tubule
Na/ K ATPase
Theme: Oesophgeal disease
A.Schatzki ring
B.Plummer Vinson syndrome
C.Squamous cell carcinoma
D.Barretts oesophagus
E.Pharyngeal pouch
F.Adenocarcinoma
G.Leiomyoma
H.Oesophageal rupture
I.Diffuse oesophageal spasm
J.Hiatus hernia
Please select the most likely underlying diagnosis for the scenario described. Each option may be used once, more than once or not at all.
A 56 year old man who drinks heavily is found collapsed by friends at his house. He was out drinking the previous night and following this was noted to have vomited repeatedly so his friends brought him home.
A 43 year old man has been troubled with dysphagia for many years. He is known to have achalasia and has had numerous dilatations. Over the past 6 weeks his dysphagia has worsened. At endoscopy a friable mass is noted in the oesophagus.
A 73 year old lady is troubled by episodic swallowing difficulty and halitosis. An upper GI endoscopy is attempted and abandoned due to difficulty in achieving intubation.
Oesophageal rupture
Spontaneous rupture of the oesophagus may occur following an episode of vomiting. The subsequent mediastinitis can produce severe sepsis and death if not treated promptly. Adequate drainage of sepsis and early surgery are the cornerstones of management.
Squamous cell carcinoma
The risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia. The condition often presents late and has a poor prognosis.
The correct answer is Pharyngeal pouch
Pharyngeal pouches occur when a defect occurs in killians dehiscence. Difficulty in intubation is a well recognised consequence and care must be taken to take the correct track during OGD to avoid perforation. Most cases are now treated with endoscopic stapling.
Complete disruption of the oesophageal wall in absence of pre-existing pathology. Left postero-lateral oesophageal is commonest site (2-3cm from OG junction). Suspect in patients with severe chest pain without cardiac diagnosis and signs suggestive of pneumonia without convincing history, where there is history of vomiting. Erect CXR shows infiltrate or effusion in 90% of cases(1).
Oesophageal rupture
Surgical occlusion of which of these structures, will result in the greatest reduction in hepatic blood flow?
Portal vein
Common hepatic artery
Right hepatic artery
Coeliac axis
Left hepatic artery
The portal vein transports 70% of the blood supply to the liver, while the hepatic artery provides 30%. The portal vein contains the products of digestion. The arterial and venous blood is dispersed by sinusoids to the central veins of the liver lobules; these drain into the hepatic veins and then into the IVC. The caudate lobe drains directly into the IVC rather than into other hepatic veins.
A 43 year old man is due to undergo an excision of the sub mandibular gland. Which of the following incisions is the most appropriate for this procedure?
A transversely orientated incision 4cm below the mandible
A transversely orientated incision immediately inferior to the mandible
A vertical incision 3 cm anterior to the angle of the mandible and extending inferiorly
A transversely orientated incision 2cm above the mandible
A transversely orientated incision 12cm below the mandible
To access the sub mandibular gland a transverse incision 4cm below the mandible should be made. Incisions located higher than this may damage the marginal mandibular branch of the facial nerve.
A 55 year old man presents with symptoms of dyspepsia and on upper GI endoscopy an area of patchy erythematous tissue is identified protruding proximally from the gastro oesophageal junction. A biopsy is diagnostic of Barretts oesophagus with low grade dysplasia. Which of the following is the most appropriate management?
Distal oesophagectomy
Upper GI endoscopy with quadrantic biopsies from the region
Photodynamic therapy
Endoscopic sub mucosal resection of the area
Argon plasma coagulation
In Barrett’s surveillance the safest option is quadrantic (i.e. 4 biopsies, one from each quarter of the oesophagus at 2cm intervals)
Low grade dysplasia in conjunction with Barretts oesphagus should be monitored with regular (6 monthly) upper GI endoscopy and quadrantic biopsies. If the disease remains static at 2 years then the screening frequency may be decreased.
A 5 year old boy presents with recurrent headaches. As part of his assessment he undergoes an MRI scan of his brain. This demonstrates enlargement of the lateral and third ventricles. Where is the most likely site of obstruction?
Foramen of Luschka
Foramen of Magendie
Foramen of Munro
Aqueduct of Sylvius
None of the above
The CSF flows from the 3rd to the 4th ventricle via the Aqueduct of Sylvius.
CSF circulation
- Lateral ventricles (via foramen of Munro)
- 3rd ventricle
- Cerebral aqueduct (aqueduct of Sylvius)
- 4th ventricle (via foramina of Magendie and Luschka)
- Subarachnoid space
- Reabsorbed into the venous system via arachnoid granulations into superior sagittal sinus
Which of the following would be the optimal fluid management option for a 45 year old man due to undergo an elective right hemicolectomy?
Remain “nil by mouth” for at least 6 hours pre-operatively and avoid intra venous fluids
Remain “nil by mouth” for at least 6 hours pre-operatively and receive supplementary intravenous 5% dextrose to replace lost calories
Allow him free access to oral fluids only until 30 minutes prior to surgery
Administer a carbohydrate based loading drink 3 hours pre operatively, and avoid intravenous fluids
Administer a carbohydrate based loading drink 6 hours pre-operatively and administer 5% dextrose saline thereafter
Administer a carbohydrate based loading drink 3 hours pre operatively, and avoid intravenous fluids
Patients for elective surgery should not have solids for 6 hours pre-operatively. However, clear fluids may be given up to 2 hours pre-operatively. Enhanced recovery programmes are now the standard of care in many countries around the world and involve administration of carbohydrate loading drinks.
The routine administration of 5% dextrose in the scenarios given above would convey little in the way of benefit and increase the risks of electrolyte derangement post operatively
A 23 year old man is undergoing an inguinal hernia repair. The surgeons mobilise the spermatic cord and place it in a hernia ring. A small slender nerve is identified superior to the cord. Which nerve is it most likely to be?
Iliohypogastric nerve
Pudendal nerve
Femoral branch of the genitofemoral nerve
Ilioinguinal nerve
Obturator nerve
The ilioinguinal nerve passes through the inguinal canal and is the nerve most commonly identified during hernia surgery. The genitofemoral nerve splits into two branches, the genital branch passes through the inguinal canal within the cord structures. The femoral branch of the genitofemoral nerve enters the thigh posterior to the inguinal ligament, lateral to the femoral artery. The iliohypogastric nerve pierces the external oblique aponeurosis above the superficial inguinal ring.
Which of the following physiological changes do not occur following tracheostomy?
Alveolar ventilation is increased.
Anatomical dead space is reduced by 50%.
Work of breathing is increased.
Proportion of ciliated epithelial cells in the trachea may decrease.
Splinting of the larynx may lead to swallowing difficulties.
Work of breathing is decreased which is one reasons it is popular option for weaning ventilated patients. Humidified air in this setting helps to reduce the viscosity of mucous that forms.
Where does the spinal cord terminate in neonates?
L1
L2
L3
L4
L5
At the 3rd month the foetus’s spinal cord occupies the entire length of the vertebral canal. The vertebral column then grows longer exceeding the growth rate of the spinal cord. This results with the cord being at L3 at birth and L1-2 by adulthood.
A 45 year old man is undergoing a low anterior resection for a carcinoma of the rectum. Which of the following fascial structures will need to be divided to mobilise the mesorectum from the sacrum and coccyx?
Denonvilliers fascia
Colles fascia
Sibsons fascia
Waldeyers fascia
None of the above
Fascial layers surrounding the rectum:
Anteriorly lies the fascia of Denonvilliers
Posteriorly lies Waldeyers fascia
Waldeyers fascia separates the mesorectum from the sacrum and will need to be divided.
Theme: Gallstone disease
A.Uncomplicated biliary colic
B.Acute cholecystitis
C.Cholangitis
D.Gallbladder abscess
E.Acalculous cholecystitis
F.Pancreatitis
G.Gallstone ileus
Please select the most likely underlying diagnosis for the scenario given. Each option may be used once, more than once or not at all.
50.A 68 year old man with type 2 diabetes is admitted to hospital unwell. On examination he has features of septic shock and right upper quadrant tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder.
A 43 year old lady with known gallstones is admitted with a high fever and jaundice. On examination, she looks extremely unwell. Her abdomen is generally soft although there is some mild tenderness in the right upper quadrant.
A 34 year old lady is admitted with a 3 day history of colicky right upper quadrant pain which radiates to her back. The pain is now more constant. On examination she is not jaundiced, but has a temperature of 38.5oC. She has localised peritonism in the right upper quadrant.
Acalculous cholecystitis
Acalculous cholecystitis is more common in patients with an underlying co-morbidity. The morbidity and mortality following intervention are higher than in conventional gallstone disease.
Cholangitis
Features of jaundice, fever and systemic sepsis are typical of cholangitis.
Acute cholecystitis
The features of pain and fever with right upper quadrant pain are suggestive of acute cholecystitis. The short nature of the history makes an abscess less likely.
Risks of ERCP
Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 1.5%
A 10 year old child has a grommet inserted for a glue ear. What type of epithelium is present on the external aspect of the tympanic membrane?
Stratified squamous
Ciliated columnar
Non ciliated columnar
Non stratified squamous
None of the above
The external aspect of the tympanic membrane is lined by stratified squamous epithelium. This is significant clinically in the development of middle ear infections when this type of epithelium may migrate inside the middle ear.
Features of the external ear
Auricle is composed of elastic cartilage covered by skin. The lobule has no cartilage and contains fat and fibrous tissue.
External auditory meatus is approximately 2.5cm long.
Lateral third of the external auditory meatus is cartilaginous and the medial two thirds is bony.
The region is innervated by the greater auricular nerve. The auriculotemporal branch of the trigeminal nerve supplies most the of external auditory meatus and the lateral surface of the auricle.
Innervation of the external ear?
Greater auricular nerve.
The auriculotemporal branch of the trigeminal nervie supplies most of the external auditory meatus and the lateral surface of the auricle
Features of the middle ear
Space between the tympanic membrane and cochlea. The aditus leads to the mastoid air cells is the route through which middle ear infections may cause mastoiditis. Anteriorly the eustacian tube connects the middle ear to the naso pharynx.
The tympanic membrane consists of:
Outer layer of stratified squamous epithelium.
Middle layer of fibrous tissue.
Inner layer of mucous membrane continuous with the middle ear.
The tympanic membrane is approximately 1cm in diameter.
The chorda tympani nerve passes on the medial side of the pars flaccida.
The middle ear is innervated by the glossopharyngeal nerve and pain may radiate to the middle ear following tonsillectomy.
Innervation of the middle ear
Glossopharyngeal nerve- pain may radiate to the middle ear following tonisllectomy
What are the ossicles
Malleus attaches to the tympanic membrane (the Umbo).
Malleus articulates with the incus (synovial joint).
Incus attaches to stapes (another synovial joint).
Features of the internal ear
Cochlea, semi circular canals and vestibule
Organ of corti is the sense organ of hearing and is located on the inside of the cochlear duct on the basilar membrane.
Vestibule accommodates the utricule and the saccule. These structures contain endolymph and are surrounded by perilymph within the vestibule.
The semicircular canals lie at various angles to the petrous temporal bone. All share a common opening into the vestibule.
A 73 year old lady is admitted with acute mesenteric ischaemia. A CT angiogram is performed and a stenotic lesion is noted at the origin of the superior mesenteric artery. At which of the following levels does this branch from the aorta?
L1
L2
L3
L4
L5
The SMA leaves the aorta at L1. It passes under the neck of the pancreas prior to giving its first branch the inferior pancreatico-duodenal artery.
A 42 year old man from Southern India presents with chronic swelling of both lower legs, they are brawny and indurated with marked skin trophic changes. Which of the following organisms is the most likely origin of this disease process?
Loa loa
Wuchereria bancrofti
Trypanosoma cruzi
Trypanosoma gambiense
None of the above
W. Bancrofti is the commonest cause of filariasis leading to lymphatic obstruction. Infection with Loa loa typically occurs in the African sub continent and usually results in generalised sub cutaneous infections without lymphatic obstruction. Trypanosomal infections would not produce this clinical picture.
Parasitic filarial nematode
Accounts for 90% of cases of filariasis
Usually diagnosed by blood smears
Usually transmitted by mosquitos
Treatment is with diethylcarbamazine
Wuchereria bancrofti
The following statements relating to the musculocutaneous nerve are true except?
It arises from the lateral cord of the brachial plexus
It provides cutaneous innervation to the lateral side of the forearm
If damaged, then extension of the elbow joint will be impaired
It supplies the biceps muscle
It runs beneath biceps
It supplies biceps, brachialis and coracobrachialis. If damaged then elbow flexion rather than extension will be impaired.
Which of the following structures does not pass through the foramen ovale?
Lesser petrosal nerve
Accessory meningeal artery
Maxillary nerve
Emissary veins
Otic ganglion
Mnemonic: OVALE
O tic ganglion
V3 (Mandibular nerve:3rd branch of trigeminal)
A ccessory meningeal artery
L esser petrosal nerve
E missary veins
Which of the following is not utilised as a descriptive statistic?
Mean
Median
Mode
Z score
Standard deviation
The z score is determined using the normal distribution and is not a descriptive statistic
Which of the cranial nerves listed below is least likely to carry parasympathetic fibres?
III
VII
IX
X
II
Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)
The parasympathetic functions served by the cranial nerves include:
III (oculomotor)Pupillary constriction and accommodation
VII (facial)Lacrimal gland, submandibular and sublingual glands
IX (glossopharyngeal)Parotid
X (vagus)Heart and abdominal viscera
The optic nerve carries no parasympathetic fibres.
The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1, Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)
Please rate this question:
A 72 year old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm is located in a juxtarenal location and surgical access to the neck of aneurysm is difficult. Which of the following structures may be divided to improve access?
Cisterna chyli
Transverse colon
Left renal vein
Superior mesenteric artery
Coeliac axis
The left renal vein will be stretched over the neck of the anuerysm in this location and is not infrequently divided. This adds to the nephrotoxic insult of juxtarenal aortic surgery as a supra renal clamp is also often applied. Deliberate division of the Cisterna Chyli will not improve access and will result in a chyle leak. Division of the transverse colon will not help at all and would result in a high risk of graft infection. Division of the SMA is pointless for a juxtarenal procedure.
A 48 year old lady is being prepared for a Whipples procedure. A right sided subclavian line is inserted and then anaesthesia is induced. Following intubation the patient becomes progressively hypoxic and haemodynamically unstable. What is the most likely underlying explanation?
Drug allergy
Simple pneumothorax
Tension pneumothorax
Halothane toxicity
Haemothorax
Central lines (and particularly subclavian lines) are risk factors for the development of pneumothorax. In the context of positive pressure ventilation a tension pneumothorax is a strong possibility and would be associated with haemodynamic instability.
What is the substrate of renin?
Aldosterone
Angiotensinogen
Angiotensin converting enzyme
Angiotensin I
Angiotensin II
Renin hydrolyses angiotensinogen to form angiotensin I.
A 28 year old man is involved in a road traffic accident and sustains a flail chest injury. On arrival in the emergency department he is hypotensive. On examination; he has an elevated jugular venous pulse and auscultation of the heart reveals quiet heard sounds. What is the most likely diagnosis?
Pneumothorax
Myocardial contusion
Cardiac tamponade
Haemothorax
Ventricular septal defect
The presence of a cardiac tamponade is suggested by Becks Triad:
Hypotension
Muffled heart sounds
Raised JVP
Theme: Ankle injuries
A.Surgical fixation
B.Below knee amputation
C.Application of below knee plaster
D.Application of ankle boot
E.Application of external fixation device
F.Application of compression dressing and physiotherapy
G.Immediate reduction and application of backslab
Please select the most appropriate management for the injury type described. Each option may be used once, more than once or not at all.
A 20 year old woman trips over a step, injuring her ankle. Examination reveals tenderness over the lateral malleolus and an x-ray demonstrates an undisplaced fracture distal to the syndesmosis.
A 30 year old man injures his ankle playing football. On examination he has tenderness over both medial and lateral malleoli. X-ray demonstrates a bimalleolar fracture with a displaced distal fibula fracture, at the level of the syndesmosis and fracture of the medial malleolus with talar shift. The ankle has been provisionally reduced and splinted in the emergency department.
A 50 year old female slips on wet floor injuring her ankle. On examination, she has tenderness over the lateral and medial malleolus. X-rays demonstrate an undisplaced fracture of the distal fiibula at the level of the syndesmosis and a congruent ankle mortice.
Application of ankle boot
This is a Weber A fracture. It is a stable ankle injury and can therefore be managed conservatively. Whilst this patient could also be treated in a below knee plaster, most clinicians would nowadays treat this injury in an ankle boot. Patients should be advised to mobilise in the ankle boot, as pain allows, and can wean themselves out of the boot as the symptoms improve.
The correct answer is Surgical fixation
This is an unstable fracture pattern with a Weber B fracture of the distal fibula and a fracture of the medial malleolus. Talar shift indicates loss of ankle mortice congruity. This injury should therefore be treated with surgical fixation.
Application of below knee plaster
This is a Weber B fracture and therefore potentially unstable. Medial malleolar tenderness indicates deltoid ligament injury. As the fracture is currently undisplaced and the ankle mortice is congruent, the injury can be initially managed conservatively in a below knee plaster but the patient should be monitored in the outpatient clinic for fracture displacement in the first few weeks.
Components of the syndemosis at the ankle
The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL).
Medial ankle ligament
Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus.
Lateral ankle ligament
Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint.
Cardiac index=
Cardiac output/body surface area
An occlusion of the anterior cerebral artery may compromise the blood supply to the following structures except:
Medial inferior surface of the frontal lobe
Corpus callosum
Medial surface of the frontal lobe
Olfactory bulb
Brocas area
Brocas area is usually supplied by branches from the middle cerebral artery.
Ddx causes of hyperamylasaemia
Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis
Theme: Breast disease
A.Ductal carcinoma in situ
B.Lobular carcinoma in situ
C.Invasive ductal carcinoma
D.Invasive lobular carcinoma
E.Inflammatory carcinoma
F.Phyllodes tumour
G.Paget’s disease of the nipple
H.Fibroadenoma
I.Mucinous breast carcinoma
From the list please select the most likely diagnosis for the scenario given. Each diagnosis may be used once, more than once or not at all.
A 32 year old Indian lady presents with a diffuse swelling of the left breast. She has a 4 month old child. Clinically, she has jaundice and there is erythema of the left breast.
A 72 year old female presents with a painless breast lump. Clinically she has a 4cm diameter irregular breast mass, with no other palpable masses.
A 72 year old woman presents with 2 breast lumps. She has a history of breast cancer in the opposite breast 5 years ago.
Inflammatory carcinoma
Inflammatory breast cancers have an aggressive nature. Dissemination occurs early and is more resistant to adjuvent treatments than other types of breast cancer. Often occurs in pregnancy or lactation.
The correct answer is Invasive ductal carcinoma
A post menopausal woman is more likely to have a ductal carcinoma and they tend to occur at a single focus within the breast.
The correct answer is Invasive lobular carcinoma
This is likely to be an invasive lobular carcinoma, mainly due to the multifocal lesions and the history of previous breast cancer in the opposite breast.
Parasympathetic fibres innervating the parotid gland originate from which of the following?
Submandibular ganglion
Otic ganglion
Ciliary ganglion
Pterygopalatine ganglion
None of the above
Secretion of saliva by the parotid gland is controlled by nerve fibres originating in the inferior salivatory nucleus; these leave the brain via the tympanic nerve (branch of glossopharyngeal nerve (CN IX), travel through the tympanic plexus (located in the middle ear), and then form the lesser petrosal nerve until reaching the otic ganglion. After synapsing in the Otic ganglion, the postganglionic (postsynaptic) fibres travel as part of the auriculotemporal nerve (a branch of the mandibular nerve (V3) to reach the parotid gland.
Location of the parotid gland
Overlying the mandibular ramus anterior and inferior to the ear
Salivary duct of the parotid gland
Crosses the masseter, pierces the buccinator and drains adjacent to the 2nd upper molar tooth (stenson’s duct)
Following an oesophagogastrectomy the surgeons will anastomose the oesophageal remnant to the stomach, which of the following is not part of the layers that comprise the oesophageal wall?
Serosa
Adventitia
Muscularis propria
Submucosa
Mucosa
The oesophageal wall lacks the serosa layer
The wall lacks a serosa which can make the wall hold sutures less securely.
A 45 year old man is referred to the breast clinic with gynaecomastia. He takes the drugs listed below. Which is least likely to be the cause of his symptoms?
Spironolactone
Carbimazole
Chlorpromazine
Cimetidine
Methyldopa
Mnemonic for drugs causing gynaecomastia: DISCO
D igitalis
I soniazid
S pironolactone
C imetidine
O estrogen
Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE
M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide
Carbimazole is not associated with gynaecomastia.
Drugs causing gynaecomastia
DISCO
D igitalis
I soniazid
S pironolactone
C imetidine
O estrogen
Causes of gynaecomastia
METOCLOPRAMIDE
M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide
Which of the following structures suspends the spinal cord in the dural sheath?
Filum terminale
Conus medullaris
Ligamentum flavum
Denticulate ligaments
Anterior longitudinal ligament
The spinal cord is approximately 45cm in men and 43cm in women. The denticulate ligament is a continuation of the pia mater (innermost covering of the spinal cord) which has intermittent lateral projections attaching the spinal cord to the dura mater.
Where is the ‘safe triangle’ for chest drain insertion located?
4th intercostal space, mid axillary line
5th intercostal space, mid axillary line
4th intercostal space, mid scapular line
5th intercostal space, mid scapular line
4th intercostal space, mid clavicular line
‘Safe Triangle’ for chest drain insertion:
5th intercostal space, mid axillary line
Borders of the safe triangle for chest drain insertion
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.
A 73 year old man develops disseminated intravascular coagulation following an abdominal aortic aneurysm repair. He receives an infusion of cryoprecipitate. What is the major constituent of this infusion?
Factor VIII
Factor IX
Protein C
Protein S
Factor V
Factor 8
Indications for cryoprecipitate
Usually massive haemorrhage/uncontrolled bleeding due to haemophilia
Composition of cryoprecipitate
Factor VIII
Fibrinogen
vWF
Factor XIII
Theme: Hand disorders
A.de Quervain’s tenosynovitis
B.Dupuytren’s contracture
C.Bouchard’s nodes
D.Ganglion
E.Carpal tunnel syndrome
F.Radial nerve injury
G.Ulnar nerve injury
H.Heberden’s nodes
I.Tendon sheath infection
Please select the most likely diagnosis to account for the scenario given. Each option may be used once, more than once or not at all.
A 49 -year-old male presents with discomfort in the fingers of his left hand. On examination, the ring and little fingers of his left hand are flexed and unable to extend completely. He is able to make a fist with the hand. Palpation reveals thickened nodules on the medial half of the palm.
A 62 year old man presents after his wife commented on the unusual shape of his fingers. On examination, he has a hard swelling adjacent to the distal interphalangeal joint of his index finger of the right hand with lateral deviation of the finger tip. There is no sensory disturbance and the swelling is not tender.
A 57 year - old lady presents with a three month history of pins and needles in the fingers of the right hand, particularly at night. On examination, there is some loss of the sensation over the palmar aspect of the lateral three fingers and wasting of the thenar eminence.
Dupuytren’s contracture
Discomfort of the hand is not uncommon in Dupuytrens contracture, true pain is unusual. The disease most commonly affects the ring and little fingers.
Heberden’s nodes
These are bony outgrowths that occur in the distal interphalangeal joint in association with osteoarthritis. They may skew the finger tip sideways. Bouchards nodes are similar, but affect the proximal interphalangeal joint.
Carpal tunnel syndrome
Carpal tunnel syndrome commonly produces pain at night as the wrists are flexed during sleep. Compromise of the median nerve may produce wasting of the thenar eminence muscles.
Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage
Bouchards nodes
Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways. It typically affects the DIP joint.
Heberdens nodes
Osler’s nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.
Osler’s nodes
Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised
Ganglion
Which of the following is not characteristic of a granuloma?
Altered macrophages
Fused macrophages
Epithelioid cells
Mixture of chronic inflammatory cells
Polymorphnuclear leucocytes, cellular debris and fibrin
Polymorphnuclear leucocytes, cellular debris and fibrin
These are typical components of an abscess cavity. Polymorphonuclear leucocytes may be found in a granuloma if there is a focus of suppuration.
A 42 year old man presents with a painless lump in the left testicle that he noticed on self examination. Clinically there is a firm nodule in the left testicle, ultrasound appearances show an irregular mass lesion. His serum AFP and HCG levels are both within normal limits. What is the most likely diagnosis?
Yolk sack tumour
Seminoma
Testicular teratoma
Epididymo-orchitis
Adenomatoid tumour
Seminomas typically have normal AFP and HCG. These are usually raised in teratomas and yolk sac tumours
This man’s age, presenting symptoms and normal tumour markers make a seminoma the most likely diagnosis. Epididymo-orchitis does not produce irregular mass lesions which are painless.
Drug cause of epididymo-orchitis
Amiodarone
Theme: Large bowel obstruction
A.Ileocolic bypass
B.Loop ileostomy
C.High anterior resection
D.Insertion of self expanding metallic stent
E.Left hemicolectomy and on table colonic lavage and primary anastomosis
F.Extended right hemicolectomy and ileocolic anastomosis
G.Low anterior resection
H.Loop colostomy of the transverse colon
I.Loop colostomy of the sigmoid colon
J.Right hemicolectomy
Please select the most appropriate initial procedure for the following patients with large bowel obstruction. Each option may be used once, more than once or not at all.
A 63 year old lady presents with an obstructing cancer of the sigmoid colon. She is not peritonitic and her imaging demonstrates a solitary liver metastasis.
A 65 year old man presents with absolute constipation and abdominal pain. On examination he has marked abdominal distension. A digital rectal examination reveals an empty rectum. A rectal contrast study shows an obstructing lesion of the proximal rectum.
A 70 year old lady presents with a two day history of constipation and vomiting. On examination she has right iliac fossa tenderness and little abdominal distension. A CT scan is performed and is suggestive of an obstructing carcinoma of the colonic hepatic flexure (stage T3).
The correct answer is Insertion of self expanding metallic stent
Ideally, the distant disease should be managed first and then the primary lesion addressed. A self expanding stent is likely to achieve this and avoids a stoma.
The correct answer is Loop colostomy of the sigmoid colon
Rectal cancers should not be primarily resected prior to definitive staging and a tumour of this nature is likely to have circumferential margin involvement. Whilst a sigmoid and transverse loop colostomy would both provide an equal relief of obstruction the former procedure has the added benefit of making a subsequent resection safer, since a transverse colostomy would have to be taken down and closed during the course of subsequent surgery.
The correct answer is Right hemicolectomy
This lesion should be amenable to standard right hemicolectomy. Extending the resection to take the middle colic vessels and distal transverse colon is unlikely to provide additional oncological benefit.
Old adage in LBO
As a general rule the old adage that the sun should not rise and set on unrelieved large bowel obstruction still holds true. A caecal diameter of 12cm or more in the presence of complete obstruction with a competent ileocaecal valve and caecal tenderness is a sign of impending perforation and a relative indication for prompt surgery.
A baby is born by normal vaginal delivery at 39 weeks gestation. Initially all appears well and then the clinical staff become concerned because the baby develops recurrent episodes of cyanosis. These are worse during feeding and improve dramatically when the baby cries. The most likely underlying diagnosis is:
Choanal atresia
Oesophageal reflux
Tetralogy of Fallot
Oesophageal atresia
Congenital diaphragmatic hernia
In Choanal atresia the episodes of cyanosis are usually worst during feeding. Improvement may be seen when the baby cries as the oropharyngeal airway is used.
Congenital disorder with an incidence of 1 in 7000 births.
Posterior nasal airway occluded by soft tissue or bone.
Associated with other congenital malformations e.g. coloboma
Babies with unilateral disease may go unnoticed.
Babies with bilateral disease will present early in life as they can then only breathe through their mouth.
Treatment is with fenestration procedures designed to restore patency.
Choanal atresia
A 32 year old man presents to the acute surgical unit with acute pancreatitis. Over the next few days he becomes dyspnoeic and his saturations are 89% on air. A CXR shows bilateral pulmonary infiltrates. His CVP pressure is 16mmHg. What is the most likely diagnosis?
Cardiac failure
Pneumococcal pneumonia
Staphylococcal pneumonia
Pneumocystis carinii
Adult respiratory distress syndrome
Acute pancreatitis is known to precipitate ARDS. ARDS is characterised by bilateral pulmonary infiltrates and hypoxaemia. Note that pulmonary oedema is excluded by the CVP reading < 18mmHg.
A 28 year old lady presents with a pigmented lesion on her calf. Excisional biopsy confirms a diagnosis of melanoma measuring 1cm in diameter with a Breslow thickness of 0.1mm. The lesion is less than 1 mm at all resection margins. Which of the following surgical resection margins is acceptable for this lesion?
5 cm
1 cm
0.5 cm
2 cm
3 cm
1cm
Margins of excision related to Breslow thickness
Lesions 0-1mm thick
1cm
Margins of excision-Related to Breslow thickness
Lesions 1-2mm thick
1- 2cm (Depending upon site and pathological features)
Margins of excision-Related to Breslow thickness
Lesions 2-4mm thick
2-3 cm (Depending upon site and pathological features)
Margins of excision-Related to Breslow thickness
Lesions >4 mm thick
3cm
A 53 year old lady has undergone a bilateral breast augmentation procedure many years previously. The implants are tense and uncomfortable and are removed. During their removal the surgeon encounters a dense membrane surrounding the implants, it has a coarse granular appearance. The tissue is sent for histology and it demonstrates fibrosis with the presence of calcification. The underlying process responsible for these changes is:
Hyperplasia
Dysplasia
Metastatic calcification
Dystrophic calcification
Necrosis
Breast implants often become surrounded by a pseudocapsule and this may secondarily then be subjected to a process of dystrophic calcification.
Deposition of calcium deposits in tissues that have undergone degeneration, damage or disease in the presence of normal serum calcium levels
Dystrophic calcification
Deposition of calcium deposits in tissues that are otherwise normal in the presence of increased serum calcium levels
Metastatic calcification
A 72 year old female is found to have a malignant lesion in her left arm. She had a mastectomy of the left breast 10 years ago and has chronic lymph oedema of the left arm. What is the most likely cause of the malignancy?
Lymphangiosarcoma
Lymphoma
Myeloma
Angiomyolipoma
Giant cell tumour
Lymphangiosarcoma is a rare condition arising as a result of chronic oedema. It is an aggressive malignancy.
def: lymphoedema
Due to impaired lymphatic drainage in the presence of normal capillary function.
Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening.
Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a ‘buffalo hump’ on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.
Primary causes of lymphoedema
Congenital < 1 year: sporadic, Milroy’s disease
Onset 1-35 years: sporadic, Meige’s disease
> 35 years: Tarda
Secondary causes of lymphoedema
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis
Indications for surgery in lymphoedema
Marked disability or deformity from limb swelling
Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
Lymphocutaneous fistulae and megalymphatics
Homans procedure
For lymphoedema
Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.
Charles operation
For lymphoedema
All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
Lymphovenous anastamosis
For lymphoedema
Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
Theme: Complications following renal transplant
A.Ureteric anastomotic leak
B.Renal vein thrombosis
C.Acute rejection
D.Chronic allograft nephropathy
E.Renal artery thrombosis
F.Renal artery stenosis
G.Lymphocele
H.Hyperacute rejection
For each of the patients described below, please select the most appropriate underlying explanation for the situation described. Each option may be used once, more than once or not at all.
A 45 year old lady undergoes a renal transplant from a living related donor. She is well for several months but on review in the outpatient department is noted to have persistent hypertension and a slight deterioration in renal function.
A 39 year old lady undergoes a live related renal transplant. She progresses well. Two weeks following the transplant she is noted to have swelling overlying the transplant site and swelling of the ipsilateral limb.Urine output is acceptable and creatinine unchanged.
Renal artery stenosis
Renal artery stenosis typically occurs over several months and will usually result in the development of hypertension. Most cases can be assessed using duplex scanning and managed with angioplasty.
The correct answer is Renal artery thrombosis
Sudden loss of urine output is most commonly due to a blocked catheter. However, if this is excluded (and is not included in the options) the most worrisome cause is arterial thrombosis. This will often be a delayed diagnosis and the rate of graft loss is high.
Lymphocele
Swelling over the graft site is often due to a lymphocele and this is further suggested by the normal renal function. They cause symptoms through mass effect and limb swelling may occur. Treatment is often surgical.
Renal artery thrombosis vs renal vein thrombosis following renal transplant
These may involve the donor vessels, those of the recipient or both. Renal artery thrombosis usually occurs early post transplant, but is uncommon with an incidence of less than 1%. It typically results in graft loss. It usually occurs as a result of a technical problem such a vessel torsion or sub intimal flaps. The usual presenting feature is a sudden cessation of urine output. When suspected, the occlusion is usually well demonstrated with duplex scanning. Ideally immediate surgical re-exploration should occur. Sadly, the graft has usually been lost by this stage and will require graft nephrectomy. Renal vein thrombosis is not as common as arterial graft thrombosis and the usual presenting features include discomfort at the graft site and swelling of the graft associated with loss of urine output. Again, duplex scanning is indicated. Unfortunately, this complication is also associated with a high incidence of graft loss.
Urological complications of renal transplant
Urinary tract complications manifesting as leakage or obstruction are common complications following renal transplantation and occur in up to 10% of patients. The main underlying cause is the relatively poor blood supply to the transplanted ureter. Patients typically present relatively early in the first 5 weeks following transplantation with pain and swelling at the graft site. Imaging with USS is often the initial test. Therapeutic options include surgical re-implantation of the ureter for large leaks and stent insertion and nephrostomy placement for smaller leaks.
Occurs within minutes of clamp release
Due to pre formed antibodies
Immediate loss of graft occurs
Hyperacute
Occurs in first few days following surgery
Involved both cellular and antibody mediated injury
Pre-sensitisation of the donor is a common cause
Accelerated acute
Traditionally the most common type of rejection
Seen days to weeks after surgery
Predominantly a cell mediated process mediated by lymphocytes
Organ biopsy demonstrates cellular infiltrates and graft cell apoptosis
Acute
Increasingly common problem
Typically; graft atrophy and atherosclerosis are seen. Fibrosis often occurs as a late event
Chronic
Your consultant decides to perform an open inguinal hernia repair under local anaesthesia. Which of the following dermatomal levels will require blockade?
T10
T12
T11
S1
S2
T12
If a sample is normally distributed which of the following is true?
Mean = standard deviation
Mean = standard error of the mean
Mean = median
Mean = variance
The mode and standard error of the mean have the same value
In a normally distributed sample, the mean, median and mode are the same.
Theme: Use of suture materials and closure devices
A.Silk 3/0
B.Polyglactin 3/0
C.Polydioxanone 1/0
D.Stainless steel skin clips
E.Stainless steel wire 1/0
F.6/0 Polypropylene
G.3/0 Undyed polyglactin
H.Polypropylene 3/0
Please select the most appropriate suture material for the situation described. Each option may be used once, more than once or not at all.
35.Mass closure of abdominal wall following elective right hemicolectomy through a midline incision.
Closure of the sternum following coronary artery bypass grafting.
Application of vein patch to femoral artery following endarterectomy.
- Polydioxanone 1/0
PDS or polydioxanone is the ideal suture material. Non absorbable sutures have higher incidence of incisional herniae.
2. Stainless steel wire 1/0
Stainless steel wire is typically used.
3. The correct answer is 6/0 Polypropylene
Polypropylene is the suture of choice. Fine sutures are preferred.
Suture material:
Classification:
Silk
Braided biological
Suture material:
Classification:
Catgut
Braided biological
Suture material:
Classification:
Chromic catgut
Braided biological
Suture material:
Classification:
Polydiaxanone (PDS)
Synthetic monofilament
Suture material:
Classification:
Polyglycolic acid (Vicryl, Dexon)
Braided synthetic
Suture material:
Classification:
Polypropylene (prolene)
Synthetic monofilament
Suture material:
Classification:
Polyester
Synthetic braided
Suture material- durability:
Silk
Theoretically permanent, although strength not preserved
Suture material- durability
Catgut
5-7d
Suture material- durability
Chromic catgut
Up to 12w
Suture material- durability
PDS
Up to 3/12 (longer with thicker sutures)
Suture material- durability
Polyglycolic acid
6/52
Suture material- durability
Polypropylene
Permanent
Suture material- durability
Polyester
Permanent
Suture material- uses:
Silk
Anchoring devices, skin closure
Suture material- uses:
Cat gut
Short term wound approximation
Suture material- uses:
Chromic catgut
Apposition of deeply sited tissues
Suture material- uses:
PDS
Widespread surgical applications including visceral anastomoses, dermal closure, mass closure of abdominal wall
Suture material- uses:
Polyglycolic acid
Most tissues can be apposed using polyglycolic acid
Suture material- uses:
Prolene
Widely used, agent of choice for vascular anastomoses
Suture material- uses:
Polyester
its combination of permanency and braiding make it useful for laparoscopic surgery
Suture material- special points:
Silk
Knots easily, poor cosmesis
Suture material- special points:
Catgut
Poor cosmesis
Degrades rapidly
Not used in UK
Suture material- special points:
Chromic catgut
Unpredictable degradation pattern
Not in use in UK
Suture material- special points:
PDS
Used in most surgical specialties (avoid dyed form in dermal closure)
Suture material- special points:
Polyglycolic acid
Good handling properties
Suture material- special points:
Prolene
Poor handling properties
Suture material- special points:
Polyester
More expensive with considerable drag
When should absorbable sutures be used
Consider absorbable sutures in situations where long term tissue apposition is not required. In cardiac and vascular surgery non absorbable sutures are usually used.
Suture size
The higher the index number the smaller the suture i.e. : 6/0 prolene is finer than 1/0 prolene.
Finer sutures have less tensile strength. For example 6/0 prolene would not be a suture suitable for abdominal mass closure but would be ideal for small calibre distal arterial anastomoses.
Why are braided sutures not used in vascular surgery?
as they are potentially thrombogenic.
Theme: Familial polyposis syndromes
A.Peutz-Jeghers syndrome
B.Cowden disease
C.Familial adenomatous polyposis coli
D.Lynch syndrome
E.MYH associated polyposis
Please select the familial cancer syndrome that most closely matches the description provided. Each option may be used once, more than once or not at all.
1.A syndrome consisting of a PTEN mutation and intestinal hamartomas.
A syndrome which may be present in a patient with multiple intestinal hamartomas and pigmentation spots around the mouth.
A syndrome likely to be present in a 28 year old man who presents with a locally advanced mucinous carcinoma of the caecum. There are scanty polyps in the remaining colon. His father died from colorectal cancer aged 34.
Cowden disease
PTEN is a tumour supressor gene and loss of function mutations result in up regulation of the mTOR pathway.
Peutz-Jeghers syndrome
The correct answer is Lynch syndrome
Lynch syndrome is likely when right sided colonic cancers occur at a young age. These tumours are often poorly differentiated and mucinous. The Amsterdam criteria can be used to identify families at risk who may benefit from genetic testing
A 48 year old lady has previously undergone a sigmoid colectomy for carcinoma. On follow up imaging she is found to have a 3cm foci of metastatic disease in segment IV of the liver. What is the most appropriate course of action?
Palliative chemotherapy
External beam radiotherapy
Brachytherapy
Surgical resection alone
Chemotherapy followed by surgical resection
The treatment of colorectal liver metastasis is usually with chemotherapy followed by surgical resection. Where surgery is performed for liver metastasis with curative intent, the 5 year survival is 20%. Palliation would generally only be considered if the patient were frail or widespread disease found on imaging. Radiotherapy is not part of the treatment of liver metastasis.
Which of the following are not characteristic features of central chemoreceptors in the control of ventilation?
They are located in the medulla oblongata
They are stimulated primarily by venous hypercapnia
They are relatively insensitive to hypoxia
They may be affected by changes in the pH of CSF
During acute hypercapnia the carotid receptors will be stimulated first
They are stimulated by arterial carbon dioxide. They take longer to equilibrate than the peripheral chemoreceptors located in the carotid. They are less exposed to acidity due to the blood brain barrier.
A 48 year old lady with end stage renal failure receives a cadaveric renal transplant. The organ is ABO group matched only. On completion of the vascular anastomoses the surgeons remove the clamps. Over the course of the next twelve minutes the donated kidney becomes dusky and swollen and appears non viable. Which of the following is the most likely process that has caused this event?
IgG anti HLA Class I antibodies in the recipient
IgM anti HLA Class I antibodies in the recipient
IgG anti HLA Class I antibodies from the donor
IgM anti HLA Class I antibodies from the donor
IgM anti HLA Class II antibodies from the recipient
Episodes of hyperacute rejection are typically due to preformed antibodies. ABO mismatch is the best example. However, IgG anti HLA Class I antibodies are another potential cause. These events are now seen less commonly because the cross matching process generally takes this possibility into account
IgG anti HLA Class I antibodies in the recipient
A 44 year old man is undergoing a parotidectomy and the surgeon is carefully preserving the facial nerve. Unfortunately his trainee then proceeds to divide it. Which of the following will not be affected as a result?
Taste sensation from anterior two thirds of the tongue
Closing the ipsilateral eyelid
Raising the ipsilateral side of the lip
Ipsilateral corneal reflex
None of the above
The chorda tympani branches inside the facial canal and will therefore be unaffected by this most unfortunate event! The corneal reflex is mediated by the opthalmic branch of the trigeminal nerve sensing the stimulus on the cornea, lid or conjunctiva; the facial nerve initiates the motor response of the reflex.
Supply of the facial nerve
Face: muscles of facial expression
Ear: nerve to stapedius
Taste: supplies anterior two-thirds of tongue
Tear: parasympathetic fibres to lacrimal glands, also salivary glands
Overview of the path of facial nerve
Subarachnoid
Facial canal path
Sytlomastoid foramen
Face
Subarachnoid path of the facial nerve
Origin: motor- pons, sensory- nervus intermedius.
Pass through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. Here they combine to become the facial nerve
Facial canal path of facial nerve
The canal passes superior to the vestibule of the inner ear.
At the medial aspect of the middle ear it becomes wider and contains the geniculate ganglion.
3 branches: 1 greater pterosal nerve. 2. nerve to stapedius. 3. chorda tympani
Passage of the facial nerve through the stylomastoid formaen
Passes through the foramen (tympanic cavity anterior and mastoid antrum posteriorly)
Posterior auricular nerve and branch to posterior belly of digastric and stylohyoid muscle
Where does the facial nerve divide into 5 branches and what are they
As it enters the parotid
Temproal
Zygomatic
Buccal
Marginal mandibular branch
Cervical branch
A 45 year old lady develops severe back pain and on examination is found to have clinical evidence of an L5/ S1 radiculopathy. Her symptoms deteriorate and eventually a laminectomy is performed. During a posterior surgical approach the surgeons encounter a tough ligamentous structure lying anterior to the spinous processes. This structure is most likely to be the
Transverse spinal ligament
Supraspinal ligament
Anterior longitudinal ligament
Ligamentum flavum
Posterior longitudinal ligament
Ligamentum flavum
Deltoid nerve root
C5,6
Biceps nerve root
C5,6
Wrist extensors nerve root
C6-8
Triceps nerve root
C6-8
Wrist flexors nerve root
C6-T1
Hand muscle nerve root
C8-T1
Theme: Pathological fractures
A.Osteosarcoma
B.Osteomalacia
C.Osteoporosis
D.Metastatic carcinoma
E.Osteoblastoma
F.Giant cell tumour
G.Ewing’s sarcoma
For each pathological fracture please select the most likely aetiology for the scenario given. Each option may be used once, more than once or not at all.
A 30 year old woman presents with pain and swelling of the left shoulder. There is a large radiolucent lesion in the head of the humerus extending to the subchondral plate.
A 72 year old woman has a lumbar vertebral crush fracture. She has hypocalcaemia and a low urinary calcium.
A 16 year old boy presents with severe groin pain after kicking a football. Imaging confirms a pelvic fracture. A previous pelvic x-ray performed 2 weeks ago shows a lytic lesion with ‘onion type’ periosteal reaction.
Giant cell tumour
Giant cell tumours on x-ray have a ‘soap bubble’ appearance. They present as pain or pathological fractures. They commonly metastasize to the lungs.
Osteomalacia
Hypocalcemia and low urinary calcium are biochemical features of osteomalacia. Unfortunately surgeons do need to look at some blood results!
Ewing’s sarcoma
A Ewings sarcoma is most common in males between 10-20 years. It can occur in girls. A lytic lesion with a lamellated or onion type periosteal reaction is a classical finding on x-rays. Most patients present with metastatic disease with a 5 year prognosis between 5-10%.
Classify the causes of pathological fractures
Metastatic tumours
Bone disease
Local benign conditions
Primary malignant tumours
The cell of origin in virtually all pancreatic carcinomas is which of the following?
The acinar cells
The islet beta cells
The islet alpha cells
The interstitial fibroblasts
The ductular epithelium
Over 90% of pancreatic carcinomas are adenocarcinomas and are thus of ductular epithelial origin.
Ix in pancreatic carcinoma
USS: May miss small lesions
CT Scanning (pancreatic protocol). If unresectable on CT then no further staging needed
PET/CT for those with operable disease on CT alone
ERCP/ MRI for bile duct assessment
Staging laparoscopy to exclude peritoneal disease
Which of the following does not pass through the superior orbital fissure?
Lacrimal nerve
Abducens nerve
Opthalmic artery
Trochlear nerve
Superior opthalmic vein
Mnemonic for the nerves passing through the supraorbital fissure:
Live Frankly To See Absolutely No Insult
Lacrimal
Frontal
Trochlear
Superior Division of Oculomotor
Abducens
Nasociliary
Inferior Division of Oculomotor nerve
The opthalmic artery arises from the internal carotid immediately after it has pierced the dura and arachnoid. It runs through the optic canal below the optic nerve and within its dural and arachnoid sheaths. It terminates as the supratrochlear and dorsal nasal arteries
An 18 year old man undergoes a tonsillectomy for attacks of recurrent acute tonsillitis. Whilst in recovery he develops a post operative haemorrhage. Which of the following vessels is the most likely culprit?
Facial vein
External palatine vein
External carotid artery
Internal jugular vein
None of the above
The external palatine vein lies immediately lateral to the tonsil and if damaged may be a cause of reactionary haemorrhage following tonsillectomy.
Anatomy of the tonsils
Each palatine tonsil has two surfaces, a medial surface which projects into the pharynx and a lateral surface embedded in the wall of the pharynx
Usually 2.5cm tall and 1.5cm wide. although varies according to age and are usually completely atrophied in the elderly.
Arterial supply comes from the tonsilar artery (branch of the facial artery)
Veins pierce the constrictor muscle to join the external palatine or facial veins.
Lymphatic drainage of the tonsils
Jugulodigastric node and deep cervical nodes
Why may delayed otalgia occur following tonsillectomy
Due to irritation of the glossopharyngeal nerve
Theme: Local anaesthetics
A.1% xylocaine with 1 in 200,000 adrenaline
B.1% Lignocaine
C.0.5% Bupivacaine with 1 in 200,000 adrenaline
D.0.5% Bupivicaine
E.Prilocaine 1%
F.Procaine 1%
G.Cocaine 25%
H.Cocaine 10%
Please select the local anaesthetic formulation most appropriate to the procedure indicated. Each option may be used once, more than once or not at all.
A 25 year old male presents with epistaxis, the ENT SpR plans to cauterise the bleeding point with silver nitrate.
An 18 year old boy requires a Zadeks procedure
A 72 year old woman fractured her distal radius. A Biers Block is planned to facilitate reduction of the fracture.
The correct answer is 1% xylocaine with 1 in 200,000 adrenaline
Historically cocaine was popular for the management of epistaxis. Some surgeons will still routinely use cocaine paste for this indication. Its popularity stems from the fact that it causes vasospasm. However, systemic absorption carries the risk of adverse reactions. Where it is used the correct dose is 4%. Topically applied short acting local anaesthetic agents with adrenaline may produce similar effects, with lower risks of toxicity.
The correct answer is 1% Lignocaine
This is excision of the toe nail and a fast acting local anaesthetic is indicated. Adrenaline should be avoided in this setting as it can cause digital ischaemia
Prilocaine 1%
This is the best local anaesthetic for this. Bupivacaine may cause cardiotoxicity and should be avoided.
When is bupivacaine use contraindicated
It is cardiotoxic and is therefore contra indicated in regional blockage in case the tourniquet fails.
Use of prilocaine
Similar mechanism of action to other local anaesthetic agents. However, it is far less cardiotoxic and is therefore the agent of choice for intravenous regional anaesthesia e.g. Biers Block.
Why are local anaesthetic agents less effective where abscesses are present
All local anaesthetic agents dissociate in tissues and this contributes to their therapeutic effect. The dissociation constant shifts in tissues that are acidic e.g. where an abscess is present, and this reduces the efficacy.
Which of the nerves listed below is responsible for providing innervation to the lower molar teeth?
Greater palatine nerve
Nasopalatine nerve
Inferior alveolar nerve
Zygomatic nerve
Mandibular nerve
The branches of the lower molar and premolar teeth are supplied by branches of the inferior alveolar nerve. Those of the canine and incisors by the incisive branch of the same nerve. The gingiva and supporting structures are innervated by the lingual nerve.
Which of the anaesthetic agents below is most likely to induce adrenal suppression?
Sodium thiopentone
Midazolam
Propofol
Etomidate
Ketamine
Etomidate is a recognised cause of adrenal suppression, this has been associated with increased mortality when used as a sedation agent in the critically ill.
Rapid onset of anaesthesia
Pain on IV injection
Rapidly metabolised with little accumulation of metabolites
Proven anti emetic properties
Moderate myocardial depression
Widely used especially for maintaining sedation on ITU, total IV anaesthesia and for daycase surgery
Propofol
Extremely rapid onset of action making it the agent of choice for rapid sequence of induction
Marked myocardial depression may occur
Metabolites build up quickly
Unsuitable for maintenance infusion
Little analgesic effects
Sodium thiopentone
May be used for induction of anaesthesia
Has moderate to strong analgesic properties
Produces little myocardial depression making it a suitable agent for anaesthesia in those who are haemodynamically unstable
May induce state of dissociative anaesthesia resulting in nightmares
Ketamine
Has favorable cardiac safety profile with very little haemodynamic instability
No analgesic properties
Unsuitable for maintaining sedation as prolonged (and even brief) use may result in adrenal suppression
Post operative vomiting is common
Etomidate
Theme: Thyroid neoplasms
A.Follicular carcinoma
B.Anaplastic carcinoma
C.Medullary carcinoma
D.Papillary carcinoma
E.Lymphoma
F.Hashimotos thyroiditis
G.Graves disease
For the following histological descriptions please select the most likely underlying thyroid neoplasm. Each option may be used once, more than once or not at all.
20.A 22 year old female undergoes a thyroidectomy. The resected specimen shows a non encapsulated tumour with papillary projections and pale empty nuclei.
A 32 year old lady undergoes a thyroidectomy for a mild goitre. The resected specimen shows an intense lymphocytic infiltrate with acinar destruction and fibrosis.
Papillary carcinoma
The presence of papillary structures together with the cytoplasmic features described is strongly suggestive of papillary carcinoma. They are seldom encapsulated.
Follicular carcinoma
Hurthle cell tumours are a variant of follicular neoplasms in which oxyphil cells predominate. They have a poorer prognosis than conventional follicular neoplasms.
Hashimotos thyroiditis
Lymphocytic infiltrates and fibrosis are typically seen in Hashimotos thyroiditis. In Lymphoma only dense lymphatic type tissue is usually present.
Theme: Diagnosis and management of post operative complications
A.Trans anal ultrasound scan
B.Upper abdominal ultrasound scan
C.Total abdominal ultrasound scan
D.PET CT scan
E.ERCP
F.Small bowel MRI Scan
G.Abdominal CT scan with oral and IV contrast
H.Non contrast abdominal CT scan
I.Laparotomy
J.Laparoscopy
For the following post operative scenarios please select the most appropriate investigation or management. Each option may be used once, more than once or not at all.
1.A 7 year old boy develops a persistent fever following an open appendicectomy for gangrenous appendicitis. On examination he has erythema of the wound and some abdominal distension.
A 56 year old man is 8 days following a left hemicolectomy. He has developed a swinging pyrexia over the past 48 hours and has an ileus clinically.
A 43 year old lady underwent an acute cholecystectomy for cholecystitis. A drain is left during the procedure. Over the next 5 days the drain has been accumulating between 100-200ml of bile per 24 hour period.
Total abdominal ultrasound scan
This patient has risk factors for a wound infection which is not in itself an indication for scanning. However, he also had abdominal distension and this, together with the history of distension would generally attract a recommendation for imaging. A USS will show an abdominal wall collection and more importantly any phrenic or pelvic collections. Unlike adult practice, CT scanning is rarely performed in children.
Abdominal CT scan with oral and IV contrast
This would most likely be the result of an anastomotic leak with abscess formation. Detailed imaging is required to allow accurate diagnosis and planning of management.
ERCP
The most likely cause of a bile leak in this scenario would be a dislodged clip from the cystic duct. Whilst it may be tempting to try and plan to manage this surgically the anatomy is often unfavorable and the duct very difficult to identify. An ERCP has the advantage of demonstrating the cause of the leak and allowing placement of a stent. This will usually allow the resolution of most leaks without the need for surgery.
At which level does the aorta perforate the diaphragm?
T10
T9
T8
T11
T12
Memory aid:
T8 (8 letters) = vena cava
T10 (10 letters) = oesophagus
T12 (12 letters) = aortic hiatus
A 24 year old lady is stabbed in the buttock. Following the injury the wound is sutured in the emergency department. Eight weeks later she attends the clinic, as she walks into the clinic room she has a waddling gait and difficulty with thigh abduction. On examination she has buttock muscle wasting. Which nerve has been injured?
Superior gluteal nerve
Obturator nerve
Sciatic nerve
Femoral nerve
Inferior gluteal nerve
Damage to the superior gluteal nerve will result in a Trendelenburg gait.
Outline the Trendelenberg test
Injury or division of the superior gluteal nerve results in a motor deficit that consists of weakened abduction of the thigh by gluteus medius, a disabling gluteus medius limp and a compensatory list of the body to the weakened gluteal side. The compensation results in a gravitational shift so that the body is supported on the unaffected limb.
When a person is asked to stand on one leg, the gluteus medius usually contracts as soon as the contralateral leg leaves the floor, preventing the pelvis from dipping towards the unsupported side. When a person with paralysis of the superior gluteal nerve is asked to stand on one leg, the pelvis on the unsupported side descends, indicating that the gluteus medius on the affected side is weak or non functional ( a positive Trendelenburg test).
This eponymous test also refers to a vascular investigation in which tourniquets are placed around the upper thigh, these can help determine whether saphenofemoral incompetence is present.
Which of the following does not stimulate insulin release?
Gastrin
Atenolol
Protein
Secretin
Vagal cholinergic action
Beta blockers inhibit the release of insulin.
Stimulation of insulin release:
Glucose
Amino acid
Vagal cholinergic
Secretin/Gastrin/CCK
Fatty acids
Beta adrenergic drugs
At which level is the hilum of the left kidney located?
L1
L2
T12
T11
L3
Remember L1 (‘left one’) is the level of the hilum of the left kidney
During a radical neck dissection, division of which of the following fascial layers will expose the ansa cervicalis?
Pretracheal fascia
Carotid sheath
Prevertebral fascia
Investing layer of fascia
Sibsons fascia
The ansa cervicalis lies anterior to the carotid sheath. It may be exposed by division of the pretracheal fascia at the posterolateral aspect of the thyroid gland. The pre vertebral fascia lies more posteriorly and division of the investing layer of fascia will not expose this nerve.
Ansa cervicalis
Superior root: Branch of C1 anterolateral to carotid sheath
Inferior root: Derived from C2 and C3 roots, passes posterolateral to the internal jugular vein (may lie either deep or superficial to it)
Innervation:
Sternohyoid
Sternothyroid
Omohyoid
Clinical significance of ansa cervicalis
The ansa cervicalis lies anterior to the carotid sheath. The nerve supply to the inferior strap muscles enters at their inferior aspect. Therefore when dividing these muscles to expose a large goitre, the muscles should be divided in their upper half.
A 43 year old lady with hypertension is suspected of having a phaeochromocytoma. Which of the following investigations is most likely to be beneficial in this situation?
Dexamethasone suppression test
Urinary 5-Hydroxyindoleacetic Acid (5-HIAA)
Histamine provocation test
Tyramine provocation test
Urinary vanillymandelic acid measurements
Urinary VMA measurements are not completely specific but constitute first line assessment. Stimulation tests of any sort are not justified in first line assessments.
Rule of 10s in phaeochromocytoma
10% of cases are bilateral.
10% occur in children.
11% are malignant (higher when tumour is located outside the adrenal).
10% will not be hypertensive.
Diagnosis of phaeochromocytoma
Urine analysis of vanillymandelic acid (VMA) is often used (false positives may occur e.g. in patients eating vanilla ice cream!)
Blood testing for plasma metanephrine levels.
CT and MRI scanning are both used to localise the lesion.
Treatment of phaeochromocytoma
Patients require medical therapy first. An irreversible alpha adrenoreceptor blocker should be given, although minority may prefer reversible blockade(1). Labetolol may be co-administered for cardiac chronotropic control. Isolated beta blockade should not be considered as it will lead to unopposed alpha activity.
These patients are often volume depleted and will often require moderate volumes of intra venous normal saline perioperatively.
Surgical
Surgical management of phaeochromocytoma
Once medically optimised the phaeochromocytoma should be removed. Most adrenalectomies can now be performed using a laparoscopic approach(2). The adrenals are highly vascular structures and removal can be complicated by catastrophic haemorrhage in the hands of the inexperienced. This is particularly true of right sided resections where the IVC is perilously close. Should the IVC be damaged a laparotomy will be necessary and the defect enclosed within a Satinsky style vascular clamp and the defect closed with prolene sutures. Attempting to interfere with the IVC using any instruments other than vascular clamps will result in vessel trauma and make a bad situation much worse.
Adrenal lesions may be identified on CT scanning performed for other reasons(3). Factors suggesting benign disease on CT include(4):
Size less than 3cm
Homogeneous texture
Lipid rich tissue
Thin wall to lesion
All patients with incidental lesions should be managed jointly with an endocrinologist and full work up as described above. Patients with functioning lesions or those with adverse radiological features (Particularly size >3cm) should proceed to surgery.
An 8 year old boy falls onto an outstretched hand and is brought to the emergency department. He is examined by a doctor and a bony injury is cleared clinically. He re-presents a week later with pain in his hand. What is the most likely underlying injury?
Fracture of the distal radius
Fracture of the scaphoid
Dislocation of the lunate
Rupture of flexor pollicis longus tendon
Bennett’s fracture
Scaphoid fractures in children are rare, will usually involve the distal pole and are easily missed. The initial clinical examination (and sometimes x-rays) may be normal and repeated clinical examination and imaging is advised for this reason. Whilst the other injuries may be sustained from a fall onto an outstretched hand they are less likely to be overlooked on clinical examination. In the case of a Bennetts fracture, the injury mechanism is less compatible with this type of injury.
What are the commonest carpal fractures?
Scaphoid fractures
Management of scaphoid fractures?
Non-displaced: casts or splints. percutaneous scaphoid fixation.
Displaced: surgical fixation with a screw
Complications of scaphoid fracture
Non union of scaphoid
Avascular necrosis of the scaphoid
Scapholunate disruption and wrist collapse
Degenerative changes of the adjacent joint
A 73 year old lady presents with symptoms of faecal incontinence. On examination she has weak anal sphincter muscles. What are the main nerve root values of the nerves supplying the external anal sphincter?
S2,3
L5, S1
S4,5
S5
S2,3,4
S2, 3, 4 Keeps the poo off the floor
The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve, this has root values of S2, 3 and the perineal branch of S4.
A 22 year old falls over and lands on a shard of glass. It penetrates the palmar aspect of his hand, immediately lateral to the pisiform bone. Which of the following structures is most likely to be injured?
Palmar cutaneous branch of the median nerve
Lateral tendons of flexor digitorum superficialis
Ulnar artery
Flexor carpi radialis tendons
Lateral tendons of flexor digitorum profundus
The ulnar nerve and artery are at most immediate risk in this injury. This is illustrated in the image below
Theme: Cranial nerve lesions
A.Optic nerve
B.Oculomotor nerve
C.Trigeminal nerve
D.Facial nerve
E.Abducens nerve
F.Glossopharyngeal nerve
G.Vestibulocochlear nerve
H.Accessory nerve
I.Hypoglossal nerve
For each of the scenarios given please give the most likely cranial nerve responsible for the symptom or lesion described. Each nerve may be used once, more than once or not at all.
- A 63 year old man is admitted with severe headache, nausea and recent epileptic fit. Fundoscopy shows papilloedema. He is also noted to have diplopia.
- A 32 year old lady is admitted with weakness, visual disturbance and peri orbital pain. On examination, she is noted to have mydriasis and diminished direct response to light shone into the affected eye. The consensual response is preserved when light is shone into the unaffected eye.
- An 18 year old boy undergoes an uncomplicated tonsillectomy for recurrent attacks of tonsillitis. Post operatively he complains of otalgia.
Abducens nerve
The long intracranial course of this nerve makes it susceptible to damage early in the course of raised ICP.
Optic nerve
This describes a relative afferent pupillary defect (RAPD). RAPD is a defect in the direct response to light. It is due to damage in optic nerve or severe retinal disease. If an optic nerve lesion is present the affected pupil will not constrict to light when light is shone in the that pupil during the swinging flashlight test. However, it will constrict if light is shone in the other eye (consensual response).
The most likely cause for this is an optic neuritis (not really surgical!). Other causes include ischemic optic disease or retinal disease, severe glaucoma causing trauma to optic nerve and direct optic nerve damage (trauma, radiation, tumor).
Glossopharyngeal nerve
The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.
A 63 year old female is referred to the surgical clinic with an iron deficiency anaemia. Her past medical history includes a left hemi colectomy but no other co-morbidities. At what site is most dietary iron absorbed?
Stomach
Duodenum
Proximal ileum
Distal ileum
Colon
Iron is best absorbed from the proximal small bowel (duodenum and jejunum) in the Fe 2+ state. Iron is transported across the small bowel mucosa by a divalent membrane transporter protein (hence the improved absorption of Fe 2+). The intestinal cells typically store the bound iron as ferritin. Cells requiring iron will typically then absorb the complex as needed.
Absorption of Fe
Duodenum and upper jejunum
About 10% of dietary iron absorbed
Fe2+ (ferrous iron) much better absorbed than Fe3+ (ferric iron)
Ferrous iron is oxidized to form ferric iron, which is combined with apoferritin to form ferritin
Absorption is regulated according to body’s need
Increased by vitamin C, gastric acid
Decreased by proton pump inhibitors, tetracycline, gastric achlorhydria, tannin (found in tea)
Transport of Fe
In plasma as Fe bound to transferrin
Storage of iron
Ferritin in bone marrow
Which of the following structures lies posterior to the femoral nerve in the femoral triangle?
Adductor longus
Pectineus
Psoas major
Iliacus
None of the above
The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and pectineus muscles.
Root values of the femoral nerve
L2, 3, 4
Femoral nerve innervates
Pectineus
Sartorius
Quadriceps femoris
Vastus lateralis/medialis/intermedius
Branches of the femoral nerve
Medial cutaneous nerve of thigh
Saphenous nerve
Intermediate cutaneous nerve of thigh
Mnemonic for femoral nerve supply
(don’t) M I S V Q Scan for PE
M edial cutaneous nerve of the thigh
I ntermediate cutaneous nerve of the thigh
S aphenous nerve
V astus
Q uadriceps femoris
S artorius
PE ectineus
A 46 year old lady presents with symptoms of diarrhoea, weight loss of 10 Kg and a skin rash of erythematous blisters involving the abdomen and buttocks. The blisters have an irregular border and both intact and ruptured vesicles. What is the most likely diagnosis?
Colonic adenocarcinoma
Pancreatic adenocarcinoma
Tropical sprue
Glucagonoma
Insulinoma
Glucagonoma is strongly associated with necrolytic migratory erythema.
Rare pancreatic tumours arising from the alpha cells of the pancreas.
Glucagon levels markedly elevated.
Symptoms include diarrhoea, weight loss and necrolytic migratory erythema.
A serum level of glucagon >1000pg/ml usually suggests the diagnosis, imaging with CT scanning is also required.
Treatment is with surgical resection. However, careful staging is required for these tumours are usually malignant and non resectable.
Glucagonoma
You are assisting in an open right adrenalectomy for a large adrenal adenoma. The consultant is distracted and you helpfully pull the adrenal into the wound to improve the view. Unfortunately this is followed by brisk bleeding. The vessel responsible for this is most likely to be:
Portal vein
Phrenic vein
Right renal vein
Superior mesenteric vein
Inferior vena cava
It drains directly via a very short vessel. If the sutures are not carefully tied then it may be avulsed off the IVC. An injury best managed using a Satinsky clamp and a 6/0 prolene suture.
Relationships of the right adrenal
Diaphragm-Posteriorly, Kidney-Inferiorly, Vena Cava-Medially, Hepato-renal pouch and bare area of the liver-Anteriorly
Relationships of the left adrenal
Crus of the diaphragm-Postero- medially, Pancreas and splenic vessels-Inferiorly, Lesser sac and stomach-Anteriorly
Arterial supply of the suprarenal glands
Superior adrenal artery from inferior phrenic artery
Middle adrenal artery from aorta
Inferior adrenal arteries from renal arteries
Venous drainage of right adrenal
Via one central vein directly into IVC
Venous drainage of the left adrenal
Via one central vein into the LRV
A 28 year old lady requires an episiotomy for a ventouse vaginal delivery. Which of the nerves listed below will usually be anaesthetised to allow the episiotomy?
Femoral
Ilioinguinal
Pudendal
Genitofemoral
Sacral plexus
The pudendal nerve innervates the posterior vulval area and is routinely blocked in procedures such as episiotomy.
Nerve roots of the pudendal nerve
S2, 3, 4
Passage of the pudendal nerve
Exits the pelvis through the GSF and re-enters via the LSF.
Travels inferiorly
Structures innervated by the pudendal nerve
Anal sphincters and EUS.
Also provides cutaneous innervation to the region of the perineum surrounding the anus and posterior vulva
A motorcyclist is involved in a road traffic accident. He suffers a complex humeral shaft fracture which is plated. Post operatively he complains of an inability to extend his fingers. Which of the following structures is most likely to have been injured?
Ulnar nerve
Radial nerve
Median nerve
Axillary nerve
None of the above
Mnemonic for radial nerve muscles: BEST
B rachioradialis
E xtensors
S upinator
T riceps
The radial nerve is responsible for innervation of the extensor compartment of the forearm.
Which of the following visceral anastomoses has the lowest risk of anastomotic leak? You may assume that all are constructed in ideal circumstances.
Stapled ileocolic anastomosis
Hand sewn anastomosis of the proximal ileum
Stapled colorectal anastomosis defunctioned with loop ileostomy
Stapled colorectal anastomosis defunctioned with loop colostomy
Hand sewn oesophagojejunal anastomosis
Rectal and oesophageal surgery have some of the highest rates of anastomotic leakage. Following anterior resection leaks are quoted to occur in up to 10% of cases. Small bowel anastomoses are the most technically forgiving. Factors increasing the risk of anastamotic leakage include previous irradiation, sepsis, malnutrition, poor blood supply and poor technique.
The defunctioning of rectal anastomoses may reduce the clinical impact of anastomotic leak and make it amenable to percutaneous drainage, but does not necessarily reduce the incidence of leaks themselves.
What are the three criteria for an anastomosis to heal?
Adequate blood supply
Mucosal apposition
Minimal tension
When these are compromised the anastomosis may break down. Even in the best surgical hands some anastomoses are more prone to dehiscence than others. Oesophageal and rectal anastomoses are more prone to leakage and reported leak rates following oesophageal and rectal surgery can be as high as 20%. This figure includes radiological leaks and those with a clinically significant leak will be of a lower order of magnitude. As a rule small bowel anastomoses heal most reliably.
Key points about vascular anastomoses
Always use non absorbable monofilament suture (e.g. Polypropylene).
Round bodied needle.
Correct size for anastamosis ( i.e. 6/0 prolene for bottom end of a femoro-distal bypass).
Suture should be continuous and from inside to outside of artery to avoid raising an intimal flap.
An enthusiastic surgical registrar undertakes his first solo splenectomy. The operation is far more difficult than anticipated and the registrar leaves a tube drain to the splenic bed at the end of the procedure. Over the following 24 hours approximately 500ml of clear fluid has entered the drain. Biochemical testing of the fluid is most likely to reveal:
Elevated creatinine
Elevated triglycerides
Elevated glucagon
Elevated amylase
None of the above
During splenectomy the tail of the pancreas may be damaged. The pancreatic duct will then drain into the splenic bed, amylase is the most likely biochemical finding. Glucagon is not secreted into the pancreatic duct.
Theme: Jaundice
A.Gilberts syndrome
B.Crigler Najjar syndrome
C.Hepatocellular carcinoma
D.Mirizzi syndrome
E.Hepatitis A
F.Hepatitis E
G.Bile duct stones
H.Multi cystic liver disease
Please select the most likely cause of jaundice for the scenario given. Each option may be used once, more than once or not at all.
- A 22 year old man returns to the UK from holiday in India. He presents with painless jaundice. On examination he is not deeply jaundiced and there is no organomegaly.
- A 56 year old man presents with jaundice. He has a long history of alcohol misuse. On examination he is jaundiced and ultrasound shows multiple echo dense lesions in both lobes of the liver. His alpha feto protein is elevated 6 times the normal range
- A 32 year old man who has suffered from Crohns disease for many years presents with intermittent jaundice. When it occurs it is obstructive in nature. It then usually resolves spontaneously.
Hepatitis A
Infective hepatitis is the most likely cause. In the UK, foreign travel is a common cause of developing infectious hepatitis, of which hepatitis A is the most common.
Hepatocellular carcinoma
HCC may complicate cirrhosis. AFP is often raised in HCC.
Bile duct stones
Bile salts are absorbed in the terminal ileum. When this process is impaired as in Crohns the patient may develop gallstones, if these pass into the CBD then obstructive jaundice will result.
A 48 year old lady is undergoing an axillary node clearance for breast cancer. Which of the structures listed below are most likely to be encountered during the axillary dissection?
Cords of the brachial plexus
Thoracodorsal trunk
Internal mammary artery
Thoracoacromial artery
None of the above
Beware of damaging the thoracodorsal trunk if a latissimus dorsi flap reconstruction is planned.
The thoracodorsal trunk runs through the nodes in the axilla. If injured it may compromise the function and blood supply to latissimus dorsi, which is significant if it is to be used as a flap for a reconstructive procedure.
A 56 year old lady is referred to the colorectal clinic with symptoms of pruritus ani. On examination a polypoidal mass is identified inferior to the dentate line. A biopsy confirms squamous cell carcinoma. To which of the following lymph node groups will the lesion potentially metastasise?
Internal iliac
External iliac
Mesorectal
Inguinal
None of the above
Lesions distal to the dentate line drain to the inguinal nodes. Occasionally this will result in the need for a block dissection of the groin.
A 56 year old man presents with symptoms of neuropathic facial pain and some weakness of the muscles of facial expression on the right side. On examination he has a hard mass approximately 6cm anterior to the right external auditory meatus. What is the most likely diagnosis?
Pleomorphic adenoma
Adenocarcinoma
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Lymphoma
The patient is most likely to have a malignant lesion within the parotid. Of the malignancies listed; adenoid cystic carcinoma has the greatest tendency to perineural invasion.
Prognosis for patients with facial weakness caused by parotid malignancies
80% will have nodal metastasis
5ys of 25%
30% of all parotid malignancies
Usually low potential for local invasiveness and metastasis (depends mainly on grade)
Mucoepidermoid carcinoma
Unpredictable growth pattern
Tendency for perineural spread
Nerve growth may display skip lesions resulting in incomplete excision
Distant metastasis more common (visceral rather than nodal spread)
5 year survival 35%
Adenoid cystic carcinoma
Often a malignancy occurring in a previously benign parotid lesion
Mixed tumours
Parotid tumour
Intermediate grade malignancy
May show perineural invasion
Low potential for distant metastasis
5 year survival 80%
Acinic cell carcinoma
Parotid carcinoma
Develops from secretory portion of gland
Risk of regional nodal and distant metastasis
5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement
Adenocarcinoma
Large rubbery lesion, may occur in association with Warthins tumours
Diagnosis should be based on regional nodal biopsy rather than parotid resection Treatment is with chemotherapy (and radiotherapy)
Lymphoma
A 45 year old women with breast cancer is started on a chemotherapy regime containing epirubicin. What is the primary mode of action of this drug?
Intercalation of DNA
Antimetabolite
Monoclonal antibody to epidermal growth factor
Inhibition of DNA gyrase
Inhibition of topoisomerase 1
Intercalation of DNA
5FU class
Antimetabolite
5FU MOA
S phase specific drug, mimics uracil and is incorporated into RNA
Class doxorubicin
Anthracyclines
MOA doxorubicin
Inhibits DNA and RNA synthesis by intercalating base pairs
Class etoposide
Topoisomerase inhibitors
MOA etoposide
Inhibits topoisomerase II prevents efficient DNA coiling
Class cisplatin
Platinum
MOA cisplatin
Crosslinks DNA, this then distorts molecules and induces apoptosis
MOA cyclophosphamide
Alkylating agent
MOA cyclophosphomide
Forms DNA crosslinks and then cell death
Class docetaxal
Taxanes
MOA docetaxal
Disrupts microtubule formation
Main adverse effect of anthracyclines
Cardiotoxicity
Why is tamoxifen associated with endometrial cancer
Tamoxifen is used and works as a partial oestrogen receptor agonist. It will typically block activity at the breast. It does, however, stimulate the receptors at other sites and it is this that accounts for its association with endometrial cancer. In post menopausal women the process of aromatisation accounts for most oestrogen production. Therefore in this group aromatase inhibitors are the preferred agents. Women who are perimenopausal start on tamoxifen and switch at 3 years.
Most common CTx in breast cancer
The FEC regime is most commonly used (Fluorouracil, epirubicin and cyclophosphamide). This was found to be superior to the older CMF regime. The Taxanes are commonly used in high risk patients and in this setting a regime of docetaxal, doxorubicin and cyclophosphamide may be used. The anthracycline class drugs have marked cardiotoxicity (a property that they share with trastuzumab) and this can limit their use.
Which of the following cancers is not associated with the human papillomavirus?
Anal cancer
Oropharyngeal cancer
Tracheal cancer
Vulval cancer
Penile cancer
HPV is associated with:
- Cervical cancer (HPV 16/18 most common)
- Anal cancer
- Penile cancer
- Vulval cancer
- Oropharyngeal cancer
A 28 year old man has a long history of recurrent chest infections. On examination, he is noted to have no palpable vas deferens. However, both testes are located within the scrotum. What is the most likely underlying disease association?
Kleinfelters syndrome
Kallmann syndrome
Cystic fibrosis
Coeliac disease
Gardners syndrome
99% of males with cystic fibrosis will have absent vas
Absence of the vas deferens
Absence of the vas may be unilateral or bilateral
Cystic fibrosis CFTR gene mutations are the cause in 40% of cases
Some non CF cases are due to unilateral renal agenesis
Sperm harvesting may allow for assisted conception
Next question
The pathogenicity of the tubercle bacillus is due to which of the following?
Necrosis caused by expanding granulomas
Ability to multiply within fibroblasts
Delayed hypersensitivity reaction against bacteria
Effect of antibody response
Direct toxic effect on host cells
Mycobacteria stimulate a specific T cell response of cell mediated immunity. This is effective in reducing the infection, the delayed hypersensitivity also damages tissues. Necrosis occurs in TB but is usually within the granuloma.
Theme: Surgical jaundice
A.Carcinoma of the head of the pancreas
B.Bile duct stricture
C.Mirizzi syndrome
D.Bile duct stones
E.Chronic cholecystitis
F.Peri hilar lymphadenopathy
G.Fitz - Hugh Curtis syndrome
Please select the most appropriate cause of the jaundice scenario given. Each option may be used once, more than once or not at all.
A 63 year old man is admitted with obstructive jaundice that has developed over the past 3 weeks. He was previously well and on examination has a smooth mass in his right upper quadrant.
A 41 year old lady is admitted with colicky right upper quadrant pain. On clinical examination she has a mild pyrexia and is clinically jaundiced. An ultrasound scan is reported as showing gallstones and the patient is taken to theatre for an open cholecystectomy. At operation, Calots triangle is almost completely impossible to delineate.
A 72 year old man undergoes a distal gastrectomy for carcinoma of the stomach. He presents with jaundice approximately 8 months post operatively. Ultrasound of the liver and bile ducts shows no focal liver lesion and normal calibre common bile duct with intra hepatic duct dilatation.
Carcinoma of the head of the pancreas
Carcinoma of the pancreas (Courvoisiers law!). The development of jaundice in association with a smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy. A bile duct stricture would not present in this way, all the other choices are related to gallstones and Fitz Hugh Curtis syndrome is a complication of pelvic inflammatory disease.
Mirizzi syndrome
In Mirizzi syndrome the gallstone becomes impacted in Hartmans pouch. Episodes of recurrent inflammation occur and this causes compression of the bile duct. In severe cases this then progresses to fistulation. Surgery is extremely difficult as Calots triangle is often completely obliterated and the risks of causing injury to the CBD are high.
Peri hilar lymphadenopathy
Unfortunately metastatic disease is the most likely event. Peri hilar lymphadenopathy would be a common culprit.
Theme: Skin disorders
A.Basal cell carcinoma
B.Dermatofibroma
C.Pilar cyst
D.Epidermoid cyst
E.Spitz naevus
F.Seborrhoeic keratosis
G.Atypical naevus
H.Capillary cavernous haemangioma
Please select the most likely underlying nature of the skin lesion described. Each option may be used once, more than once or not at all.
18.A 70 year old lady presents with a number of skin lesions that she describes as unsightly. On examination she has a number of raised lesions with a greasy surface located over her trunk. Apart from having a greasy surface the lesions also seem to have scattered keratin plugs located within them.
A 28 year old female presents with a small nodule located on the back of her neck. It is excised for cosmetic reasons and the histology report states that the lesion consists of a sebum filled lesion surrounded by the outer root sheath of a hair follicle.
A 21 year old lady presents with a nodule on the posterior aspect of her right calf. It has been present at the site for the past 6 months and occurred at the site of a previous insect bite. Although the nodule appears small, on palpation it appears to be nearly twice the size it appears on examination. The overlying skin is faintly pigmented.
Seborrhoeic keratosis
Seborrhoeic keratosis may have a number of appearances. However, the scaly, thick, greasy surface with scattered keratin plugs makes this the most likely diagnosis.
The correct answer is Pilar cyst
Pilar cysts may contain foul smelling cheesy material and are surrounded by the outer part of a hair follicle. Because of their histological appearances they are more correctly termed pilar cysts than sebaceous cysts.
Dermatofibroma
Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at sites of previous trauma.
Most commonly arise in patients over the age of 50 years, often idiopathic
Equal sex incidence and prevalence
Usually multiple lesions over face and trunk
Flat, raised, filiform and pedunculated subtypes are recognised
Variable colours and surface may have greasy scale overlying it
Treatment options consist of leaving alone or simple shave excision
Seborrhoeic keratosis
Typically appear at, or soon after, birth
Usually greater than 1cm diameter
Increased risk of malignant transformation (increased risk greatest for large lesions)
Congenital melanocytic naevi
Circular macules
May have heterogeneous colour even within same lesion
Most naevi of the palms, soles and mucous membranes are of this type
Junctional melanocytic naevi
Domed pigmented nodules up to 1cm in diameter
Arise from junctional naevi, usually have uniform colour and are smooth
Compound naevi
Usually develop over a few months in children
May be pink or red in colour, most common on face and legs
May grow up to 1cm and growth can be rapid, this usually results in excision
Spitz naevus
Atypical melanocytic naevi that may be autosomally dominantly inherited
Some individuals are at increased risk of melanoma (usually have mutations of CDKN2A gene)
Many people with atypical naevus syndrome AND a parent sibling with melanoma will develop melanoma
Atypical naevus syndrome
Common and affect face and trunk
They have a central punctum, they may contain small quantities of sebum
The cyst lining is either normal epidermis (epidermoid cyst) or outer root sheath of hair follicle (pilar cyst)
Epidermoid cysts
Solitary dermal nodules
Usually affect extremities of young adults
Lesions feel larger than they appear visually
Histologically they consist of proliferating fibroblasts merging with sparsely cellular dermal tissues
Dermatofibroma
Which of the following ligaments contains the artery supplying the head of femur in children?
Transverse ligament
Ligamentum teres
Iliofemoral ligament
Ischiofemoral ligament
Pubofemoral ligament
Ligamentum teres
What is the reciprocal of absolute risk reduction?
Odds ratio
Number needed to treat
False positive
False negative
None of the above
In epidemiology, the absolute risk reduction, or risk difference is the decrease in risk of a given activity or treatment in relation to a control activity or treatment. It is the inverse of the number needed to treat.
def: absolute risk reduction
The absolute risk reduction is the decrease in risk of a given activity or treatment in relation to a control activity or treatment. It is the inverse of the number needed to treat.
The absolute risk reduction is usually calculated for two different treatments. For example, consider surgical resection (X) versus watchful waiting (Y) for prostate cancer. A defined end point, such as 5 year survival is required. If the probabilities pX and pY of this end point are known then the absolute risk reduction is calculated (pX-pY).
def: NNT
how many patients would need to receive a treatment to prevent one event. It is the absolute difference between two treatments.
What is used to classify humeral neck fractures?
- Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments:
-greater tuberosity
-lesser tuberosity - articular surface
- shaft
Displacement: >1cm or angulation >45 degrees.
A 15 year old boy undergoes an emergency splenectomy for trauma. He makes a full recovery and is discharged home. Eight weeks post operatively the general practitioner performs a full blood count with a blood film. Which of the following is most likely to be present?
Myofibroblasts
Howell-Jolly bodies
Multinucleate giant cells
Reed Sternberg Cells
None of the above
Post splenectomy blood film features:
Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes
As the filtration function is the spleen is no longer present Howell-Jolly bodies are found.
The loss of splenic tissue results in the inability to readily remove immature or abnormal red blood cells from the circulation. The red cell count does not alter significantly. However, cytoplasmic inclusions may be seen e.g. Howell-Jolly bodies.
In the first few days after splenectomy target cells, siderocytes and reticulocytes will appear in the circulation. Immediately following splenectomy a granulocytosis (mainly composed of neutrophils) is seen, this is replaced by a lymphocytosis and monocytosis over the following weeks.
The platelet count is usually increased and this may be persistent, oral antiplatelet agents may be needed in some patients.
A 43 year old woman is identified as being a carrier of a BRCA 1 mutation. Apart from breast cancer, which of the following malignancies is she at greatest risk of developing?
Colonic cancer
Ovarian cancer
Follicular carcinoma of the thyroid
Pituitary adenoma
Phaeochromocytoma
BRCA 1 mutation patients are 55% more likely to get ovarian cancer. Those with BRCA 2 are 25% more likely. The risk of developing other malignancies is slightly increased but not to the same extent, and not enough to justify screening.
A 53 year old man is due to undergo a splenectomy as a treatment for refractory haemolytic anaemia. The underlying pathological basis for haemolytic anaemia is thought to be a Type 2 hypersensitivity response. Which of the following mechanisms best describes this process
Deposition of immune complexes
Cell mediated immune response
IgE mediated response
Formation of autoantibodies against cell surface antigens
None of the above
Formation of autoantibodies against cell surface antigens
Mnemonic for the reactions and the mediators involved
ACID EGG-T
Type 1 Anaphylactic
Type 2 Cytotoxic
Type 3 Immune complex
Type 4 Delayed type
EGG T (mediators)
IgE
IgG
IgG
T cells
Type 2 hypersensitivity reactions (which includes haemolytic anaemia) are associated with formation of antibody against cell surface antigens.
What is the commonest type of fistula in ano?
Trans-sphincteric
Supra levator
Complex supra levator
Intersphincteric
Suprasphincteric
Intersphincteric fistulas are the commonest type and the external opening may be internal or external. These are the classical type of fistula and will have an internal opening near the anal verge and obey Goodsalls rule. Primary fistulotomy in this situation usually poses little risk to continence.
Anal fistula plugs and fibrin glue
try and improve fistula healing. Meticulous preparation of the tract and prior use of a draining seton is likely to improve chances of success.
The use of anal fistula plugs in high transphincteric fistula of cryptoglandular origin is to be discouraged because of the high incidence of non response in patients treated with such devices [9]In most patients septic complications are the reasons for failure [10]. Fibrin glue is a popular option for the treatment of fistula. There is variability of reported healing rates In some cases initial success rates of up to 50% healing at six months are reported (in patients with complex cryptogenic fistula). Of these successes 25% suffer a long term recurrence of fistula [11]. There are, however, no obvious cases of damage to the sphincter complex and the use of the devices does not appear to adversely impact on subsequent surgical options.
Ano-rectal advancement flaps
This procedure is primarily directed at high fistulae, and is considered attractive as a sphincter saving operation. The procedure is performed either with the patient in the prone jack knife position or in lithotomy (depending upon the site of the fistula). The dissection is commenced in the sub mucosal plane (which may be infiltrated with dilute adrenaline solution to ease dissection). The dissection is continued into healthy proximal tissue. This is brought down and sutured over the defect.
Follow up of patients with cryptoglandular fistulas treated with advancement flaps shows a success in up to 80% patients[12-14]. With most recurrences occurring in the first 6 months following surgery[12]. Continence was affected in some patients, with up to 10% describing major continence issues post operatively.
Ligation of the intersphincteric tract procedure
In this procedure an incision is made in the intersphincteric groove and the fistula tract dissected out in this plane and divided. A greater than 90% cure rate within 4 weeks was initially reported[15]. Others have subsequently performed similar studies on larger numbers of patients with similar success rates.
Fistulotomy at the time of abscess drainage?
A Cochrane review conducted in 2010 suggests that primary fistulotomy for low, uncomplicated fistula in ano may be safe and associated with better outcomes in relation to long term chronic sepsis[16]. However, there is a danger that such surgery performed by non specialists may result in a higher complication rate and therefore the traditional teaching is that primary treatment of acute sepsis is incision and drainage only. All agree that high/ complex fistulae should never be subject to primary fistulotomy in the acute setting.
Fistulotomy
Low fistulas, that are simple should be treated by fistulotomy once the acute sepsis has been controlled. Fistulotomy (where safe) provides the highest healing rates [5]. Because fistulotomy is regarded as having a high cure rate, there are some who prefer to use this technique with more extensive sphincter involvement. In these patients the fistulotomy is performed as for a low fistula. However, the muscle that is encountered is then divided and reconstructed with an overlapping sphincter repair. A price is paid in terms of incontinence with this technique and up to 12.5% of patients who were continent pre-operatively will have issues relating to continence post procedure[6]. The same group also randomised between fistulotomy and sphincter reconstruction and ano-rectal advancement flaps for the treatment of complex cryptoglandular fistulas and reported similar outcomes in terms of recurrence (>90%) and disturbances to continence (20%)[7].
Other authors have found adverse outcomes following fistulotomy in patients who have undergone previous surgery, are of female gender or who have high internal openings [8], in these patients careful assessment of pre-operative sphincter function should be considered mandatory prior to fistulotomy.
Seton suture
A seton is a piece of material that is passed through the fistula between the internal and external openings that allows the drainage of sepsis. This is important as undrained septic foci may drain along the path of least resistance, which may result in the development of accessory tracts and openings. Their main use is in treating complex fistula. Two types of seton are recognised, simple and cutting. Simple setons lie within the fistula tract and encourage both drainage and fibrosis. A cutting seton is inserted and the skin incised. The suture is tightened and re-tightened at regular intervals. This may convert a high fistula to a low fistula. Since the tissue will scar surrounding the fistula it is hoped that this technique will minimise incontinence[3]. Unfortunately, a large retrospective review of the literature related to the use of cutting setons has found that they are associated with a 12% long term incontinence rate [4]
A 43 year old lady is donating her left kidney to her sister and the surgeons are harvesting the left kidney. Which of the following structures will lie most anteriorly at the hilum of the left kidney?
Left renal artery
Left renal vein
Left ureter
Left ovarian vein
Left ovarian artery
The renal veins lie most anteriorly, then artery and ureter lies posteriorly.
A 31 year old lady is struck by a car and is 32 weeks pregnant. On arrival in the emergency department she has a systolic blood pressure of 105mmHg and a pulse rate of 126 beats per minute. Abdominal examination demonstrates a diffusely tender abdomen and some left sided flank bruising. A FAST scan is normal. What is the most appropriate course of action?
Arrange a departmental abdominal USS scan
Arrange an urgent abdominal MRI scan
Perform a laparotomy
Perform diagnostic peritoneal lavage
Arrange an urgent abdominal CT scan
The patient’s mechanism of injury makes a solid organ injury likely. FAST scanning is associated with a false negative rate in pregnancy which makes the negative result less reassuring. CT scanning remains the gold standard.
Imaging in the pregnant trauma patient
Sonography and FAST scanning are established in pregnancy and have the advantage of avoiding ionising radiation. However, the sensitivity of the FAST scan is reduced in pregnancy especially with advanced gestational age. Sensitivity of FAST scanning is 60-80% across all trimesters and 90% in the first. CT scanning remains the first line investigation in major trauma where significant visceral injury is suspected. The maximum permitted safe dose of radiation in pregnancy is 5mSv. A pelvic CT scan would fall below this level. That said, early exposure to radiation will increase the risk of developmental anomalies and foetal loss. Late exposure increases the risk of childhood cancer twofold. CT scanning remains the most sensitive test for identifying complications such as placental abruption in this group.
What is the sensory nerve supply to the angle of the jaw?
Maxillary branch of the trigeminal nerve
Mandibular branch of the trigeminal nerve
C3-C4
Greater auricular nerve (C2-C3)
Buccal branch of the facial nerve
The trigeminal nerve is the major sensory nerve to the face except over the angle of the jaw. The angle of the jaw is innervated by the greater auricular nerve.
A 63 year old man is undergoing a coronary artery bypass procedure. During the median sternotomy which structure would routinely require division?
Parietal pleura
Interclavicular ligament
Internal mammary artery
Brachiocephalic vein
Left vagus nerve
The interclavicular ligament lies at the upper end of a median sternotomy and is routinely divided to provide access. The pleural reflections are often encountered and should not be intentionally divided, if they are, then a chest drain will need to be inserted on the affected side as collections may then accumulate in the pleural cavity. Other structures encountered include the pectoralis major muscles, again if the incision is truly midline then these should not require formal division. The close relationship of the brachiocephalic vein should be borne in mind and it should be avoided, iatrogenic injury to this structure will result in considerable haemorrhage.
Theme: Management of skin wounds
A.Immediate split thickness skin graft
B.Delayed split thickness skin graft
C.Primary closure
D.Delayed primary closure
E.Compression bandages
F.Myocutaneous flap
G.Random free flap
For each of the following injury scenarios please select the most appropriate management. Each option may be used once, more than once or not at all.
A 63 year old male is gardening when he trips and lands on a scythe. He sustains a deep laceration of his lateral thigh, it measures 3cm depth by 7cm length, it penetrates down to the bone, but no fracture is evident on imaging or examination. His co- morbidities include type II diabetes mellitus (diet controlled) and polymyalgia rheumatica (takes regular low dose prednisolone).
A 71 year old lady trips over and falls landing on her left shin. She sustains a large pretibial laceration of her leg.
A 73 year old lady presents with an ulcer overlying her medial malleolus. It is painless and has been present for 4 months. She has oedema of the lower limbs and her ABPI measures 0.9.
The correct answer is Delayed primary closure
Wounds which are contaminated or have the potential to become so are unsafe for immediate primary closure. The combination of diabetes and steroids makes wound complications more likely. Despite his high risk a primary skin graft or flap is unlikely to be a safer option. Either may be used at a later date in the event that delayed primary closure is unsuccessful.
Delayed split thickness skin graft
Pretibial lacerations do not heal well. Simple apposition of skin edges almost always fails due to poor quality dermal tissues and underlying haematoma. Debridement of devitalised tissues prior to grafting usually gives the best results.
Compression bandages
This is likely to be a venous leg ulcer. These are typically managed using compression bandages. Contra indications to this technique include peripheral vascular disease (not present here).
Vacuum assisted closure
Uses negative pressure therapy to facilitate wound closure
Sponge is inserted into wound cavity and then negative pressure applied
Advantages include removal of exudate and versatility
Disadvantages include cost and risk of fistulation if used incorrectly on sites such as bowel
Which of the following structures separates the subclavian artery from the subclavian vein?
Scalenus anterior
Scalenus medius
Sternocleidomastoid
Pectoralis major
Pectoralis minor
The artery and vein are separated by scalenus anterior. This muscle runs from the transverse processes of C3,4,5 and 6 to insert onto the scalene tubercle of the first rib.
Branches of the subclavian artery
Vertebral artery
Internal thoracic artery
Thyrocervical trunk
Costocervical trunk
Dorsal scapular artery
A 56 year old lady is due to undergo a left hemicolectomy for carcinoma of the splenic flexure. The surgeons decide to perform a high ligation of the inferior mesenteric vein. Into which of the following does this structure usually drain?
Portal vein
Inferior vena cava
Left renal vein
Left iliac vein
Splenic vein
Beware of ureteric injury in colonic surgery.
The inferior mesenteric vein drains into the splenic vein, this point of union lies close to the duodenum and this surgical maneouvre is a recognised cause of ileus.
A man undergoes a high anterior resection for carcinoma of the upper rectum. Which of the following vessels will require ligation?
Superior mesenteric artery
Inferior mesenteric artery
Coeliac axis
Perineal artery
Middle colic artery
The IMA is usually divided during anterior resection. Not only is this borne out of oncological necessity but it also permits sufficient colonic mobilisation for anastomosis.
A 43 year old lady is due to undergo an axillary node clearance as part of treatment for carcinoma of the breast. Which of the following fascial layers will be divided during the surgical approach to the axilla?
Sibsons fascia
Pre tracheal fascia
Waldayers fascia
Clavipectoral fascia
None of the above
The clavipectoral fascia is situated under the clavicular portion of pectoralis major. It protects both the axillary vessels and nodes. During an axillary node clearance for breast cancer the clavipectoral fascia is incised and this allows access to the nodal stations. The nodal stations are; level 1 nodes inferior to pectoralis minor, level 2 lie behind it and level 3 above it. During a Patey Mastectomy surgeons divide pectoralis minor to gain access to level 3 nodes. The use of sentinel node biopsy (and stronger assistants!) have made this procedure far less common.
What are the boundaries of the ‘safe triangle’ for chest drain insertion?
Bounded by trapezius, latissimus dorsi, and laterally by the vertebral border of the scapula
Bounded by latissimus dorsi, pectoralis major, line superior to the nipple and apex at the axilla
Bounded by latissimus dorsi, serratus anterior, line superior to the nipple and apex at the axilla
Bounded by trapezius, deltoid, rhomboid major and teres minor
Bounded by trapezius, deltoid and latissimus dorsi
Bounded by latissimus dorsi, pectoralis major, line superior to the nipple and apex at the axilla
When assessing trauma patients it is worth remembering that in order to generate a palpable femoral pulse an arterial pressure of
>65mmHg is required.
Which of the following is not an oncogene?
ras
myc
sis
Ki 67
erb-B
Ki 67 is a nuclear proliferation marker (used in immunohistochemistry). Although, Ki67 positivity is a marker of malignancy, it is not itself, an oncogene.
An otherwise fit 30 year old male donates 500ml of blood. Which of the processes outlined below is most likely to occur?
Oliguria
Activation of the renin angiotensin system
Sweating
Fall in mean arterial pressure
Tachypnoea
The loss of 500ml (assuming a 70 Kg male) will usually be sufficient to activate the renin angiotensin system. It is unlikely that it would cause any other physiological disturbance.
Class I haemorrhagic shock
Bloods loss <750ml
<15%
PR normal
BP normal
RR normal
UO >30mL
Asymptomatic
Blood loss:
PR normal
BP normal
RR normal
UO >30mL
Asymptomatic
Class I
Class II haemorrhagic shock
750-1500mL
15-30%
PR >100
BP Normal
RR 20-30
UO 20-30mL
Anxious
Blood loss
PR >100
BP Normal
RR 20-30
UO 20-30mL
Anxious
Class II haemorrhagic shock
Class III haemorrhagic shock
Blood loss 1500-2000mL
30-40% blood loss
PR >120bpm
BP decreased
RR 30-40
UO 5-15mL
Confused
PR >120bpm
BP decreased
RR 30-40
UO 5-15mL
Confused
Class III haemorrhagic shock
Class IV haemorrhagic shock
>2000mL
>40% blood loss
PR >140
Reduced BP
RR >35mL
UO <5mL
Lethargic
Bloods loss
PR >140
Reduced BP
RR >35mL
UO <5mL
Lethargic
Class IV haemorrhagic shock
The vertebral artery traverses all of the following except?
Transverse process of C6
Transverse process of the axis
Vertebral canal
Foramen magnum
Intervertebral foramen
The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra, it does not traverse the intervertebral foramen.
What are the four regions of the vertebral artery
The first part runs to the foramen in the transverse process of C6. Anterior to this part lies the vertebral and internal jugular veins. On the left side the thoracic duct is also an anterior relation.
The second part runs superiorly through the foramina of the the transverse processes of the upper 6 cervical vertebrae. Once it has passed through the transverse process of the axis it then turns superolaterally to the atlas. It is accompanied by a venous plexus and the inferior cervical sympathetic ganglion.
The third part runs posteromedially on the lateral mass of the atlas. It enters the sub occipital triangle, in the groove of the upper surface of the posterior arch of the atlas. It then passes anterior to the edge of the posterior atlanto-occipital membrane to enter the vertebral canal.
The fourth part passes through the spinal dura and arachnoid, running superiorly and anteriorly at the lateral aspect of the medulla oblongata. At the lower border of the pons it unites to form the basilar artery.
A 25 year old man is injured in a road traffic accident. His right tibia is fractured and is managed by fasciotomies and application of an external fixator. Over the next 48 hours his serum creatinine rises and urine is sent for microscopy, muddy brown casts are identified. What is the most likely underlying diagnosis?
Acute interstitial nephritis
Acute tubular necrosis
Glomerulonephritis
IgA Nephropathy
Thin basement membrane disease
This patient is likely to have had compartment syndrome (tibial fracture + fasciotomies) which may produce myoglobinuria. The presence of worsening renal function, together with muddy brown casts is strongly suggestive of acute tubular necrosis. Acute interstitial nephritis usually arises from drug toxicity and does not usually produce urinary muddy brown casts. Thin basement membrane disease is an autosomal dominant condition that causes persistent microscopic haematuria, but not worsening renal function.
A 60 year old female attends the preoperative hernia clinic. She reports some visual difficulty. On examination she is noted to have a homonymous hemianopia. Where is the lesion most likely to be?
Frontal lobe
Pituitary gland
Parietal lobe
Optic chiasm
Optic tract
Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion
Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion
Unfortunately we thought as surgeons we could forget about visual field defects! However the college seem to like them. Remember a homonymous hemianopia is indicative of an optic tract lesion. Parietal lobe lesions tend to cause inferior quadranopias and there is a bitemporal hemianopia with optic chiasm lesion or pituitary tumours.
Upper quadrant defect > lower quadrant defect
inferior chiasmal compression, commonly a pituitary tumour
Homonymous quadrantanopias
Mnemonic = PITS
Parietal-Inferior, Temporal-Superior
Lower quadrant defect > upper quadrant defect
superior chiasmal compression, commonly a craniopharyngioma
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
Vagus nerve
Azygos vein
Right inferior lobar bronchus
Phrenic nerve
Pericardiophrenic artery
The azygos vein is routinely divided during an oesophagectomy to allow mobilisation. It arches anteriorly to insert into the SVC on the right hand side.
Ivor-Lewis oesophagectomy
In patients with lower third lesions an Ivor - Lewis type procedure is most commonly performed. Very distal tumours may be suitable to a transhiatal procedure. Which is an attractive option as the penetration of two visceral cavities required for an Ivor- Lewis type procedure increases the morbidity considerably.
McKeown oesophagectomy
More proximal lesions will require a total oesphagectomy (Mckeown type) with anastomosis to the cervical oesophagus.
Combined laparotomy and right thoracotomy
Ivor- Lewis procedure
Preparation for Ivor-Lewis oesophagectomy
Staging with CT CAP, if no metastatic disease detected, patients will undergo a laparoscopy to detect peritoneal disease.
If both negative a patient will undergo a PET CT scan to detect occult metastatic disease.
Patients will receive a GA, double lumen ET tube, CVP and art line
General procedure in Ivor-Lewis oesophagectomy
Rooftop incision
Laparotomy
Right thoracotomy
Ivor-Lewis oesophagectomy: laparotomy
To mobilise the stomach
The greater omentum is incised away from its attachment to the right gastroepiploic vessels along the greater curvature of the stomach.
Then the short gastric vessels are ligated and detached from the greater curvature from the spleen.
The lesser omentum is incised, preserving the right gastric artery.
The retroperitoneal attachments of the duodenum in its second and third portions are incised, allowing the pylorus to reach the oesophageal hiatus. Some surgeons perform a pyloroplasty at this point to facilitate gastric emptying.
The left gastric vessels are then ligated, avoiding any injury to the common hepatic or splenic arteries. Care must be taken to avoid inadvertently devascularising the liver owing to variations in anatomy.
Ivor-Lewis oesophagectomy- right thoracotomy
Oesophageal resection and oesophagogastric anastomosis
Through 5th intercostal space
Dissection performed 10cm above the tumour
This may involve transection of the azygos vein.
The oesophagus is then removed with the stomach creating a gastric tube.
An anastomosis is created.
How is the chest closed following Ivor Lewis oesophagectomy
The chest is closed with underwater seal drainage and tube drains to the abdominal cavity.
Post-operative management of oesophagectomy
Patients will typically recover in ITU initially.
A nasogastric tube will have been inserted intraoperatively and must remain in place during the early phases of recovery.
Post operatively these patients are at relatively high risk of developing complications:
Post-operative complications following oesophagectomy
* Atelectasis- due to the effects of thoracotomy and lung collapse
* Anastomotic leakage. The risk is relatively high owing to the presence of a relatively devascularised stomach. Often the only blood supply is from the gastroepiploic artery as all others will have been divided. If a leak does occur then many will attempt to manage conservatively with prolonged nasogastric tube drainage and TPN. The reality is that up to 50% of patients developing an anastomotic leak will not survive to discharge.
* Delayed gastric emptying (may be avoided by performing a pyloroplasty).
Which of the following statements relating to menisceal tears is false?
The medial meniscus is most often affected
True locking of the knee joint may occur
Most established tears will heal with conservative management
In the chronic setting there is typically little to find on examination if the knee is not locked
An arthroscopic approach may be used to treat most lesions
Menisci have no nerve or blood supply and thus heal poorly. Established tears with associated symptoms are best managed by arthroscopic menisectomy.
Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery
Ruptured anterior cruciate ligament
Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test
Ruptured posterior cruciate ligament
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position
Rupture of medial collateral ligament
Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to “unlock” the knee
Recurrent episodes of pain and effusions are common, often following minor trauma
Menisceal tear
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
Chondromalacia patellae
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate
Dislocation of the patella
A 25 year old man is undergoing respiratory spirometry. He takes a maximal inspiration and maximally exhales. Which of the following measurements will best illustrate this process?
Functional residual capacity
Vital capacity
Inspiratory capacity
Maximum voluntary ventilation
Tidal volume
Vital capacity
The maximum voluntary ventilation is the maximal ventilation over the course of 1 minute.
A 58 year old male is referred to endocrinology clinic for a parathyroidectomy by the F1 in medicine. His corrected calcium is 2.85 (2.2-2.6), PTH 7.5 (3-7) and 24h urinary calcium is 1.5 (2.5-7.5). What is the diagnosis?
Primary hyperparathyroidism
Secondary hyperparathyroidism
Tertiary hyperparathyroidism
Familial hypocalciuric hypercalcaemia
Hypercalacemia associated with malignancy
This F1 should have spoken to his senior. This patient has familial hypocalciuric hypercalcaemia, which requires no further action. A calcium to creatinine clearance ratio of <0.01 will confirm this diagnosis.
PTH (Elevated)
Ca2+(Elevated)
Phosphate (Low)
Urine calcium : creatinine clearance ratio > 0.01
Primary hyperparathyroidism
PTH
PTH (Elevated)
Ca2+ (Low or normal)
Phosphate (Elevated)
Vitamin D levels (Low)
Secondary hyperparathyroidism
Ca2+(Normal or high)
PTH (Elevated)
Phosphate levels (Decreased or Normal)
Vitamin D (Normal or decreased)
Alkaline phosphatase (Elevated)
Tertiary hyperparathyroidism
Indications for surgery in primary hyperparathyroidism
Elevated serum Calcium > 1mg/dL above normal
Hypercalciuria > 400mg/day
Creatinine clearance < 30% compared with normal
Episode of life threatening hypercalcaemia
Nephrolithiasis
Age < 50 years
Neuromuscular symptoms
Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)
A 56 year old man has undergone a radical nephrectomy. The pathologist bisects the kidney and identifies a pink fleshy tumour in the renal pelvis. What is the most likely disease?
Renal cell carcinoma
Transitional cell carcinoma
Angiomyolipoma
Phaeochromocytoma
Renal adenoma
Most renal tumours are yellow or brown in colour. TCC’s are one of the few tumours to appear pink.
The finding of a TCC in the renal pelvis mandates a nephroureterectomy.
A 65 year old lady presents with a lesion affecting her right breast. On examination she has a weeping, crusting lesion overlying the right nipple, the areolar region is not involved. There is no palpable mass lesion in the breast, there is a palpable axillary lymph node. The patient’s general practitioner has tried treating the lesion with 1% hydrocortisone cream, with no success. What is the most likely diagnosis?
Infection with Staphylococcus aureus
Pagets disease of the nipple
Phylloides tumour
Nipple eczema
Basal cell carcinoma
A weeping, crusty lesion such as this is most likely to represent Pagets disease of the nipple (especially since the areolar region is spared). Although no mass lesion is palpable, a proportion of patients will still have an underlying invasive malignancy (hence the lymphadenopathy).
Pagets disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).
Which of the following statements relating to quadratus lumborum is false?
Causes flexion of the thoracic spine
Causes the rib cage to be pulled down
Innervated by anterior primary rami of T12 and L1-3
Attached to the iliac crest
Inserts into the 12th rib
Quadratus lumborum
Origin: Medial aspect of iliac crest and iliolumbar ligament
Insertion: 12th rib
Action: Pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: Anterior primary rami of T12 and L1-3
The rectus abdominis causes flexion of the thoracic spine and therefore the statement suggesting that quaratus lumborum does so is incorrect.
Theme: Acute limb ischaemia
A.Primary amputation
B.Transfemoral embolectomy with prophylactic fasciotomy
C.Transpopliteal embolectomy without prophylactic fasciotomy
D.Transfemoral embolectomy without prophylactic fasciotomy
E.Transpopliteal embolectomy with prophylactic fasciotomy
F.Angiogram
G.Systemic heparin infusion
H.Peripheral thrombolysis
Please select the most appropriate management for the following patients presenting with acutely ischaemic limbs. Each option may be used once, more than once or not at all.
A 76 year old man presents with a painful left leg. The pain began suddenly and with no previous history. On examination he has a white left leg with no palpable femoral pulse and loss of sensation. The pulses in the contra lateral limb are normal. It is now three hours since the pain first started.
A 56 year old man presents with a painful left leg. The pain has been present for the past 8 hours although it has also been present (though less severe) about a week ago. At that stage he noted that his hallux had turned blue. This resolved spontaneously. On examination he has a weakly palpable femoral pulse on the affected side but no pulses palpable distal to this. His sensation is mildly impaired.
A 78 year old lady is found by carers with a severely painful left leg. On examination she has no palpable pulses and the limb is cold, insensate and mottled. The mottling does not blanch with pressure.
Transfemoral embolectomy without prophylactic fasciotomy
A limb which is acutely ischaemic and with normal contralateral pulses normally indicates an acute embolus. Whilst intra arterial thrombolysis may be an option there is a reasonable argument for immediate surgery. A fasciotomy is unlikely to be required.
The correct answer is Angiogram
The history favors a more chronic process and the great toe cyanotic spell may be indicative of previous embolism from pathology such as an aneurysm. In the ideal scenario a duplex scan would be performed. However, an angiogram would probably supply sufficient information and allow appropriate endovascular therapy.
Primary amputation
This is an unsalvagable limb and is best amputated primarily.
Clinical appearance of an acutely ischaemic leg
Less than 6 hours = White leg
At 6 -12 hours = Mottled limb with blanching on pressure
More than 12-24 hours = Fixed mottling
Role of thrombolysis in acute limb ischaemia
Intra arterial thrombolysis is better than peripheral thrombolysis
Mainly indicated in acute on chronic thrombosis
Avoid if within 2 months of CVA or 2 weeks of surgery
Aspiration of clot may improve success rate if the thrombosis is large
When should fasciotomy in acute limb ischaemia be considered?
Fasciotomy should be considered if the time between onset and surgery exceeds 6 hours
What is the commonest cause of acute limb ischaemia
Thrombosis of a pre-existing site of atherosclerosis if the commonest cause of acute limb
What type of thrombosis poses greatest threat to limb?
Acute thrombosis of popliteal aneurysms poses the greatest threat to the limb
Which of the following does not decrease the functional residual capacity?
Obesity
Pulmonary fibrosis
Muscle relaxants
Laparoscopic surgery
Upright position
Increased FRC:
Erect position
Emphysema
Asthma
Decreased FRC:
Pulmonary fibrosis
Laparoscopic surgery
Obesity
Abdominal swelling
Muscle relaxants
When the patient is upright the diaphragm and abdominal organs put less pressure on the lung bases, allowing for an increase in the functional residual capacity (FRC). Other causes of increased FRC include:
Emphysema
Asthma
In addition to those listed above, causes of reduced FRC include:
Abdominal swelling
Pulmonary oedema
Reduced muscle tone of the diaphragm
Age
A 23 year old climber falls and fractures his humerus. The surgeons decide upon a posterior approach to the middle third of the bone. Which of the following nerves is at greatest risk in this approach?
Ulnar
Antebrachial
Musculocutaneous
Radial
Intercostobrachial
The radial nerve wraps around the humerus and may be injured during a posterior approach. An IM nail may be preferred as it avoids the complex dissection needed for direct bone exposure.
Which of the following pathological explanations best describes the initial pathological processes occurring in an abdominal aortic aneurysm in an otherwise well 65 year old, hypertensive male?
Loss of elastic fibres from the adventitia
Loss of collagen from the adventitia
Loss of collagen from the media
Loss of elastic fibres from the media
Decreased matrix metalloproteinases in the adventitia
Loss of elastic fibres from the media
In established aneurysmal disease there is dilation of all layers of the arterial wall and loss of both elastin and collagen. The primary event is loss of elastic fibres with subsequent degradation of collagen fibres.
In medical statistics, which of the following does a p value of 0.04 represent?
Risk of type 1 Error
Risk of type 2 Error
Size of power of the study
Sample size
Number of degrees of freedom
P values are related to the significance levels of a statistical test and therefore are in effect measuring the risk of a type 1 error.
Type 1 Error
Test rejects true null hypothesis
Rate of type 1 error is the given the value of α
It usually equals the significance level of a test
Type 2 Error
Test fails to reject a false null hypothesis
Rate of type 2 errors is given the value of β
It is related to the power of the test
Which of the following is the main site of dehydroepiandrosterone release?
Posterior pituitary
Zona reticularis of the adrenal gland
Zona glomerulosa of the adrenal gland
Juxtaglomerular apparatus of the kidney
Zona fasciculata of the adrenal gland
Adrenal cortex mnemonic: GFR - ACD
DHEA possesses some androgenic activity and is almost exclusively released from the adrenal gland.
A 34 year old lady undergoes an elective cholecystectomy for attacks of recurrent cholecystitis due to gallstones. Microscopic assessment of the gallbladder is most likely to show which of the following?
Dysplasia of the fundus
Widespread necrosis
Aschoff-Rokitansky sinuses
Metaplasia of the fundus
None of the above
Aschoff-Rokitansky sinuses are the result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall. They may be macroscopic or microscopic. Ashoff-Rokitansky sinuses may be identified in cases of chronic cholecystitis and gallstones. Although gallstones may predispose to the development of gallbladder cancer the actual incidence of dysplasia and metaplastic change is rare. In the elective setting described above necrosis would be rare.
A 1-day-old baby girl is noted to become profoundly cyanotic whilst feeding and crying. A diagnosis of congenital heart disease is suspected. What is the most likely cause?
Transposition of the great arteries
Coarctation of the aorta
Patent ductus arteriosus
Hypoplastic left heart
Ventricular septal defect
Congenital heart disease
Cyanotic: TGA most common at birth, Fallot’s most common overall
Acyanotic: VSD most common cause
It is important to be aware of common congenital cardiac abnormalities. The main differentiating factor is whether the patient is cyanotic or acyanotic. In the neonate, TGA is the most common condition presenting with profound cyanosis.
The other options are causes of acyanotic congenital heart disease
Theme: Developmental bone disorders
A.Rickets
B.Craniocleidodysostosis
C.Achondroplasia
D.Scurvy
E.Pagets disease
F.Multiple myeloma
G.Osteogenesis imperfecta
H.Osteomalacia
I.Osteopetrosis
J.None of the above
Please select the most likely disease process to account for the clinical scenario. Each option may be used once, more than once or not at all.
- A 15 year-old boy presents to the out-patient clinic with tiredness, recurrent throat and chest infections, and gradual loss of vision. Multiple x-rays show brittle bones with no differentiation between the cortex and the medulla.
- A 12 year-old boy who is small for his age presents to the clinic with poor muscular development and hyper-mobile fingers. His x-rays show multiple fractures of the long bones and irregular patches of ossification.
- A 1 year-old is brought to the Emergency Department with a history of failure to thrive. On examination, the child is small for age and has a large head. X-ray shows a cupped appearance of the epiphysis of the wrist.
Osteopetrosis
Osteopetrosis is an autosomal recessive condition. It is commonest in young adults. They may present with symptoms of anaemia or thrombocytopaenia due to decreased marrow space. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. These bones are very dense and brittle.
Osteogenesis imperfecta
Osteogenesis imperfecta is caused by defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. There is a failure of maturation of collagen in all the connective tissues.Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.
Rickets
Rickets is the childhood form of osteomalacia. It is due to the failure of the osteoid to ossify due to vitamin D deficiency. Symptoms start about the age of one. The child is small for age and there is a history of failure to thrive. Bony deformities include bowing of the femur and tibia, a large head, deformity of the chest wall with thickening of the costochondral junction (rickettary rosary), and a transverse sulcus in the chest caused by the pull of the diaphragm (Harrison’s sulcus). X- Rays show widening and cupping of the epiphysis of the long bones, most readily apparent in the wrist.
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.
Osteogenesis imperfecta
Osteogenesis imperfecta Type 1
Normal quality collagen
Insufficient quantity
Osteogenesis imperfecta Type 2
Poor collagen quantity and quality
Osteogenesis imperfecta Type III
Collagen poorly formed
Normal quantity
Osteogenesis imperfecta Type IV
Sufficient collagen quantity but poor quality
Bones become harder and more dense.
Autosomal recessive condition.
It is commonest in young adults.
Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.
Osteopetrosis
Salter Harris Classification
SALT-C
Straight: through physis
Above: through physis and metaphysis
Lower: through physis and epiphysis to include the joint
Through: fracutre involving physis, metaphysis and epiphysis
Crush: Crush injury involving physis (may resemble Type 1)
Both sides of cortex are breached
Complete fracture
Oblique tibial fracture in infants
Toddlers fracture
Stress on bone resulting in deformity without cortical disruption
Plastic deformity
Unilateral cortical breach only
Greenstick fracture
Incomplete cortical disruption resulting in periosteal haematoma only
Buckle fracture
Which of the following are not true of Li-Fraumeni syndrome?
It consists of mutations to the p53 tumour suppressor gene
Is likely to be present in a teenager presenting with a liposarcoma
It has an autosomal dominant inheritance pattern
Affected individuals are unlikely to develop acute myeloid leukaemia
Adrenal malignancies are more common than in normal population
They are at high risk of developing leukaemia.
A.Median nerve
B.Ulnar nerve
C.Radial nerve
D.Posterior interosseous nerve
E.Anterior interosseous nerve
F.Musculocutaneous nerve
G.Axillary nerve
H.Brachial Trunks C5-6
I.Brachial trunks C6-7
J.Brachial Trunks C8-T1
Please select the most likely lesion site for each scenario. Each option may be used once, more than once or not at all.
5.A 42 year old teacher is admitted with a fall. An x-ray confirms a fracture of the surgical neck of the humerus. Which nerve is at risk?
A 32 year old window cleaner is admitted after falling off the roof. He reports that he had slipped off the top of the roof and was able to cling onto the gutter for a few seconds. The patient has Horner’s syndrome.
A 32 year old rugby player is hit hard on the shoulder during a rough tackle. Clinically his arm is hanging loose on the side. It is pronated and medially rotated.
Axillary nerve
The Axillary nerve winds around the bone at the neck of the humerus. The axillary nerve is also at risk during shoulder dislocation.
Brachial Trunks C8-T1
The patient has a Klumpke’s paralysis involving brachial trunks C8-T1. Classically there is weakness of the hand intrinsic muscles. Involvement of T1 may cause a Horner’s syndrome. It occurs as a result of traction injuries or during delivery.
Brachial Trunks C5-6
The patient has an Erb’s palsy involving brachial trunks C5-6.
Secretions from which of the following will contain the highest levels of potassium?
Rectum
Small bowel
Gallbladder
Pancreas
Stomach
The rectum has the potential to generate secretions rich in potassium. This is the rationale behind administration of resins for hyperkalaemia and the development of hypokalaemia in patients with villous adenoma of the rectum.
How dose vomiting cause hypokalaemia?
A key point to remember for the exam is that gastric potassium secretions are low. Hypokalaemia may occur in vomiting, usually as a result of renal wasting of potassium, not because of potassium loss in vomit.
Theme: Trauma
A.Tension pneumothorax
B.Haemopericardium
C.Haemothorax
D.Aortic transection
E.Ruptured spleen
F.Duodeno-jejunal flexure disruption
G.Aorto iliac disruption
H.Ileo-colic junction disruption
For each scenario please select the most likely injury. Each option may be used once, more than once or not at all.
9.A 24 year old motorist is involved in a road traffic accident in which he collides with the wall of a tunnel in a head on car crash, speed 85mph. He is wearing a seatbelt and the airbags have deployed. When rescuers arrive he is lucid and conscious and then dies suddenly.
A 30 year old women is involved in a road traffic accident she is a passenger in a car involved in a head on collision with another vehicle. Her car is travelling at 60mph. She has been haemodynamically stable throughout with only minimal tachycardia. On examination she has marked abdominal tenderness and a large amount of intra abdominal fluid on CT scan
A 17 year old boy is involved in a motorcycle accident in which he is thrown from his motorcycle. On admission he has distended neck veins and a weak pulse. The trachea is central.
Aortic transection
Aortic transections typically occur distal to the ligamentum arteriosum. A temporary haematoma may prevent the immediate death that usually occurs. This is a deceleration injury. A widened mediastinum may be seen on x-ray.
Duodeno-jejunal flexure disruption
This is another site of sudden deceleration injury. Given the large amount of free fluid, if it were blood, then a greater degree of haemodynamic instability would be expected.
Haemopericardium
This is most likely a cardiac tamponade produced by haemopericardium. As little as 100ml of blood may result in tamponade as the pericardial sac is not distensible. Diagnosis is suggested by muffled heart sounds, paradoxical pulse and jugular vein distension.
What is the typical stroke volume in a resting 70 Kg man?
10ml
150ml
125ml
45ml
70ml
70ml
Stroke volumes range from 55-100ml.
A 35 year old type 1 diabetic presents with difficulty mobilising and back pain radiating to the thigh. He has a temperature of 39 oC and has pain on extension of the hip. He is diagnosed with an iliopsoas abscess. Which of the following statements is false in relation to his diagnosis?
Staphylococcus aureus is the most likely primary cause
Recurrence occurs in 60% cases
More common in males
Crohn’s is the most likely secondary cause
CT guided drainage is preferable first line management
Recurrence occurs in 60% of cases
Classical features include: a limp, back pain and fever. Recurrence rates are about 15-20%. In the UK,Staphylococcus is the commonest primary cause, others include Streptococcus and E.coli. Management is ideally by CT guided drainage.
Primary causes of iliopsoas abscess
Haematogenous spread of bacteria
Staphylococcus aureus: most common
Secondary causes of iliopsoas abscess
Crohn’s (commonest cause in this category)
Diverticulitis, Colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
Note the mortality rate can be up to 19-20% in secondary iliopsoas abscesses compared with 2.4% in primary abscesses.
Specific tests to diagnose ilipsoas inflammation
Patient in the supine position with the knee flexed and the hip mildly externally rotated
Specific tests to diagnose iliopsoas inflammation:
Place hand proximal to the patient’s ipsilateral knee and ask patient to lift thigh against your hand. This will cause pain due to contraction of the psoas muscle.
Lie the patient on the normal side and hyperextend the affected hip. In inflammation this should elicit pain as the psoas muscle is stretched.
Ix in iliopsoas abscess
CT is gold standard
Indications for surgery in iliopsoas abscess
Failure of percutaneous drainage
Presence of another intra-abdominal pathology which requires surgery
Surgical approach to iliopsoas abscess
Review the CT scans and plan surgical approach. An extraperitoneal approach is important.
The collection usually extends inferiorly and can be accessed from an incision at a level of L4 on the affected side.
GA
Transverse laterally placed incision.
Incise external oblique.
Split the subsequent muscle layers.
As you approach the peritoneum use blunt dissection to pass laterally around it.
Remember the ureter and gonadal veins lie posterior at this level.
Eventually you will enter the abscess cavity, a large amount of pus is usually released at this point. Drain the area with suction and washout with saline.
Place a corrugated drain well into the abscess cavity.
If you have made a small skin incision it is reasonable to bring the drain up through the skin wound. Otherwise place a lateral exit site and close the skin and external oblique. If you do this ensure that you use interrupted sutures.
Which of the following statements relating to parathyroid neoplasms is incorrect?
15% of cases are due to parathyroid carcinoma
80% of cases are due to parathyroid adenomas
Parathyroid adenomas are often encapsulated
10% of parathyroid adenomas develop in ectopically located glands
85% of cases of primary hyperparathyroidism are due to solitary adenomas
Parathyroid carcinomas account for up to 5% of tumours. Adenomas are often encapsulated. Lesions that are fibrotic and densely adherent to the gland may be a carcinoma. 85% cases of primary hyperparathyroidism are due to a single adenoma and this is the reason some surgeons favour a focused parathyroidectomy.
A 20 year old girl presents with a thyroid cancer, she is otherwise well with no significant family history. On examination she has a nodule in the left lobe of the thyroid with a small discrete mass separate from the gland itself. Which of the following is the most likely cause?
Follicular carcinoma
Anaplastic carcinoma
Medullary carcinoma
Papillary carcinoma
B Cell Lymphoma
Papillary carcinoma is the most common subtype and may cause lymph node metastasis (mass separate from the gland itself) that is rare with follicular tumours. Anaplastic carcinoma would cause more local symptoms and would be rare in this age group.
Theme: Surgical energy devices
A.Monopolar diathermy
B.Bipolar diathermy
C.CUSA device
D.Argon plasma coagulation device
E.Ligasure device
F.Monopolar device in cutting mode
G.Monopolar device in coagulation mode
H.Monopolar device in blend mode
Please select the most appropriate surgical energy device for the procedure described. Each option may be used once, more than once or not at all.
17.Posterior dissection of the thyroid gland during total thyroid lobectomy
ndertaking a snare polypectomy for a villous adenoma of the descending colon
Dissection of temporal lobe for tumour
Bipolar diathermy
This will minimise thermal trauma to the recurrent laryngeal nerve
Monopolar device in blend mode
Blend applies a mixture of coagulation and cutting modes to achieve smooth polypectomy
CUSA device
The ultrasonic dissector is the preferred tool for this. It is also extensively used in liver resections
Features of monopolar diathermy
Current flows from handheld device to earth electrode.
Narrow tip produces local heath that can vaporsie and fulgurate tissues.
In cutting mode sufficeint power is applied to vaporise water content.
In coagulation mode the power level is reduced so coagulum forms instead.
Some machines have a blend mode that alternates cutting and coagulation
Features of bipolar diathermy
The electric current flows from one electrode to another however, both electrodes are usually contained within the same device e.g. a pair of forceps. The result is that heating is localised to the area between the two electrodes and surrounding tissue damage is minimised.
Ultrasound based cuttting devices
These include CUSA and Harmonic scalpel. They generate high frequency oscillations that seal and coagulate tissues. They have different energy settings that allow them to dissect and simultaneously seal vessels if required. The CUSA device leaves vessels intact that may then be divided.
Ligasure device
Delivers tailored energy levels to allow simultaneous haemostasis and dissection. The device senses the impedance of the tissues and tailors energy levels accordingly.
Hazards of diathermy
Inadvertent patient burn. This may result of careless handling of the device or in the case of monopolar devices forgetting to apply a return electrode plate, In this situation patients may develop a contact burn when electricity flows to earth
Explosion or fire. This may occur when volatile anaesthetic gases or skin preparation fluid have been used
Which of the following statements relating to quantitative data is false?
Discrete data cannot be sub divided
The median is less susceptible to extreme outliers than the mean
The mean is susceptible to extreme outliers
Data that fits the standard distribution perfectly will have a mode that is half the value of the mean
Values obtained have a numerical scale
Data that fits the standard distribution perfectly will have a mean, median and mode that are all the same value.
A 68 year old man with critical limb ischaemia is undergoing a femoro-distal bypass graft. During mobilisation of the proximal part of the posterior tibial artery which of the following is at greatest risk of injury?
Tibial nerve
Sciatic nerve
Saphenous nerve
Common peroneal nerve
Medial superior genicular artery
The tibial nerve is closely related to the posterior tibial artery. The tibial nerve crosses the vessel posteriorly approximately 2.5cm distal to its origin. At its origin the nerve lies medial and then lateral after it crosses the vessel as described.
What are the most likely effects of the release of vasopressin from the pituitary?
Vasoconstriction of the afferent glomerular arteriole
Increased permeability of the mesangial cells to glucose
Reduced permeability of the inner medullary portion of the collecting duct to urea
Increased secretion of aldosterone from the macula densa
Increased water permeability of the distal tubule cells of the kidney
ADH (vasopressin) results in the insertion of aquaporin channels in apical membrane of the distal tubule and collecting ducts.
Which of the following hormones is mainly responsible for sodium - potassium exchange in the salivary ducts?
Vasopressin
Angiotensin I
Aldosterone
Somatostatin
Cholecystokinin
Aldosterone is responsible for regulating ion exchange in salivary glands. It acts on a sodium / potassium ion exchange pump.It is a mineralocorticoid hormone derived from the zona glomerulosa of the adrenal gland.
Theme: Management of breast cancer
A.Simple mastectomy alone
B.Radical mastectomy alone
C.Simple mastectomy and sentinel lymph node biopsy
D.Wide local excision and sentinel lymph node biopsy
E.Simple mastectomy and axillary node clearance
F.Radical mastectomy and axillary node clearance
G.Wide local excision and axillary node clearance
H.Wide local excision alone
Please select the most appropriate treatment for the situation described. Each option may be used once, more than once or not at all.
27.A 44 year old lady presents with a mass in the upper outer quadrant of her right breast. Imaging, histology and clinical examination confirm a 1.5cm malignant mass lesion with no clinical evidence of axillary nodal disease.
A 44 year old lady presents with a mass lesion in the upper outer quadrant of the left breast. On clinical examination she has a 2cm mass lesion which on core biopsy is demonstrated to have invasive ductal carcinoma. An FNA of a bulky axillary lymph node contains malignant cells.
A 39 year old lady presents with a mass lesion in her right breast. Clinical examination, biopsy and imaging confirm a 2.5 cm lesion in the upper inner quadrant of her right breast and a 1.5 cm lesion at the central aspect of the same breast. Her axilla shows lymphadenopathy and a fine needle aspirate from the node shows malignant cells.
Wide local excision and sentinel lymph node biopsy
A small peripheral lesion such as this would usually be suitable for breast conserving surgery. Since imaging and clinical examination is not suspicious for axillary disease, a sentinel lymph node biopsy should be performed.
Wide local excision and axillary node clearance
Although the primary lesion is small enough for breast conserving surgery, the presence of overt axillary lymph node metastasis will attract a recommendation for axillary node clearance
Simple mastectomy and axillary node clearance
A combination of established axillary disease and multifocal invasive lesions attracts an indication for mastectomy and axillary clearance. A radical mastectomy is less frequently indicated in modern surgical practice, disease that is locally advanced is often best downstaged using medical therapy, rather than embarking on the operations for breast cancer that were first popularised over 100 years ago.
Theme: Vascular disorders affecting the upper limb
A.Proximal brachial artery occlusion secondary to atheroma
B.Distal brachial artery occlusion secondary to atheroma
C.Axillary artery embolus
D.Axillary vein thrombosis
E.Cervical rib
F.Raynaud’s disease
G.Rheumatoid disease
Please select the most likely cause for the presenting scenario described. Each option may be used once, more than once or not at all.
30.A 73 year old male presents with a collapse and is brought to the emergency department. On examination he has a cold, painful left hand and forearm.
A 23 year old man presents with intermittent symptoms of altered sensation in his arm and discomfort when he uses his hands. He works as an electrician and his symptoms are worst when he is fitting light fixtures.
A 19 year old lady presents with recurrent episodes of pain in her hands. She notices that her symptoms are worst in cold weather. When she gets the pain she notices that her hands are very pale, they then become dark blue in colour.
Sudden arterial embolus will affect the axillary artery in up to 30% cases. Because of the acute nature of the condition there is no time for the development of a collateral circulation so the limb is usually pale and painful. Emboli occur usually occur as a result of atrial fibrillation. Fast atrial fibrillation can cause syncope and an acute embolus.
Cervical rib
Compression of the thoracic outlet by the fibrous band of the “rib” can result in both neurological and circulatory compromise. When manual tasks are performed in which the hand works overhead the signs and symptoms will be maximal and this is the basis of Adsons test.
Raynaud’s disease
Raynauds disease is characterised by a series of colour changes and discomfort is often present. The young age at presentation coupled with the absence of a smoking history (in most cases) makes occlusive disease unlikely.
Describe upper limb steal mechanism
The anatomy of the collateral circulation of the arterial inflow may impact on the history and nature of disease presentation. In the region of the subclavian and axillary arteries the collateral vessels passing around the shoulder joint may provide pathways for flow if the main vessels are stenotic or occluded. During periods of increased metabolic demand the collateral flow is not sufficient and the vertebral arteries may have diminished flow. This may result in diminished flow to the brain with neurological sequelae such as syncope.
What is the most common site for upper limb emboli to lodge?
Brachial artery
What proportion of upper limb emboli will lodge in the axillary artery?
30%
Gradual onset of upper limb swelling and discomfort.
Sensation and motor function are normal
Condition may complicate pre-existing malignancy (especially breast cancer) or arise as a result of repetitive use of the limb in a task such as painting a ceiling
The condition is diagnosed with duplex ultrasound and treatment is with anticoagulation
Upper limb venous thrombosis
Adsons test
Lateral flexion of the neck away from symptomatic side and traction of the symptomatic arm- leads to obliteration of radial pulse
Seen in cervical rib
Which muscle does not insert on the medial surface of the greater trochanter?
Gemelli
Obturator internus
Piriformis
Quadratus femoris
Obturator externus
The quadratus femoris fibres pass laterally to be inserted into the quadrate tubercle on the intertrochanteric crest of the femur. The other muscles all insert on the trochanteric fossa lying medial to the greater trochanter.
Mnemonic for muscle attachment on greater trochanter is POGO:
Piriformis
Obturator internus
Gemelli
Obturator externus
What muscles are innervated by the superior gluteal nerve?
Gluteus medius
Gluteus minimis
Tensor fascia lata
What nerve innervates gluteus maximus?
Inferior gluteal nerve
During a radical gastrectomy for carcinoma of the stomach the surgeons remove the omentum. What is the main source of its blood supply?
Ileocolic artery
Superior mesenteric artery
Gastroepiploic artery
Middle colic artery
Inferior mesenteric artery
The vessels supplying the omentum are the omental branches of the right and left gastro-epiploic arteries. The colonic vessels are not responsible for the arterial supply to the omentum. The left gastro-epiploic artery is a branch of the splenic artery and the right gastro-epiploic artery is a terminal branch of the gastroduodenal artery.
A 20 year old male presents with a tense, swollen knee joint. There is no history of antecedent trauma. On examination the joint is tense and swollen but there is no sign of injury. Plain x-rays show no fracture or arthritis. What is the most likely explanation?
Rupture of the anterior cruciate ligament
Rupture of the medial collateral ligament
Tibial plateau fracture
Haemophilia A
von Willebrands disease
Haemarthrosis without trauma is typically a feature of haemophilia A and B
Without a history of trauma, ligamentous rupture or tibial plateau fractures would be unusual.
Haemarthroses may occur in 45% of patients with severe von Willebrands disease. However, this is rare
A 38 year old lady is due to undergo a parathyroidectomy for hyperparathyroidism. At operation the inferior parathyroid gland is identified as being enlarged. A vessel is located adjacent to the gland laterally. This vessel is most likely to be the:
External carotid artery
Common carotid artery
Internal carotid artery
External jugular vein
None of the above
The common carotid artery is a lateral relation of the inferior parathyroid.
A 45 year old man has a long femoral line inserted to provide CVP measurements. The catheter passes from the common iliac vein into the inferior vena cava. At which of the following vertebral levels will this occur?
L5
L4
S1
L3
L2
The common iliac veins fuse with the IVC at L5.
IVC at T8
Hepatic vein, inferior phrenic vein, pierces diaphragm
IVC at L1
Suprarenal veins, renal veins
IVC at L2
Gonadal vein
Branches of the internal caroitd artery
ACA and MCA
Ophthalmic artery
PCA
Anterior choroid artery
Meningeal arteries
Hypophyseal arteries
A 14-year-old boy is admitted to the acute surgical unit with appendicitis. He is normally fit and well. Apart from metoclopramide, the patient has had no other medications. The nursing staff contact you as the patient is acting strange. On examination he is agitated, has a clenched jaw and his eyes are deviated upwards. What is the most likely diagnosis?
Functional disorder
Malignant hyperthermia
Oculogyric crisis
Epilepsy
Serotonin syndrome
This is a classic description of an oculogyric crisis, a form of extrapyramidal disorder. An oculogyric crisis is an acute dystonic reaction. This is precipitated by antipsychotics (haloperidol) and metoclopramide in susceptible individuals with a genetic predisposition to this. Treatment is with procyclidine IM.
Ligaments of the cervical spine
